Pergamon

Sm. Sci. Med. Vol. 39, No. 5, pp. 655-670 1994 Copyright (%, 1994 Elsevier Science Ltd

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PATIENT VIEWS ON QUALITY CARE IN GENERAL PRACTICE: LITERATURE REVIEW

J. REFLY LEWIS

Health and Social Policy Research Centre, Department of Community Studies, University of Brighton, Falmer, Brighton BNl 9PH, U.K.

Abstract-The present paper examines research on patient satisfaction and the factors which influence patient attitudes regarding quality in general practice. Although data are used from U.S. and other sources, conclusions are drawn with a specific focus on a U.K. genera1 practice context. This is a research area with a growing literature, much of it based on unsystematic research. The purpose of this paper is to make a contribution to the process or ordering the data in a manner which will be of utility to those involved in the provision of healthcare and the assessment of that provision. The data suggest conclusions in two broad areas: (I) methods by which patient satisfaction may be assessed; specific published instruments are reviewed, and (2) factors which have been indicated, by the research to date, to influence patient satisfaction. Most consistently identified as being of particular value to patients are interpersonal skills on the part of the practitioner. It is suggested that such techniques should receive wider acknowledgement as a basic element of the practitioner’s technical repertoire.

We will be encouraging health authorities to continue and expand their use of questionnaires and surveys to find out what you think of the current services and to get your suggestions of how things could be done better.

The Patient’s Charter

1. INTRODUCTION

This review has been prepared as part of a research programme instigated by three Community Health Councils in South East England who wish to be able to give informed recommendations to G.P.s in their districts regarding the assessment of patient satisfac- tion. Much of the research in this field is lacking in method and stringency. Also, much of the relevant literature has been generated in the U.S. and else- where; research which should not be ignored but which can be generalised only with caution.

The present paper will attempt to draw conclusions that are relevant, specifically to General Practice in the U.K., an aim which guides the selection of data. This will not make it irrelevant elsewhere, but it is well to place this paper in an appropriate context. Data generated in one cultural setting are not auto- matically transferabale to another.* A comprehensive review that would be applicable to all health care systems, or even a few, would be beyond the scope of a single article.

*See for example Smith P. B. and Bond M. H. Social Psychology Across Cultures. Harvester Wheatsheaf, Hemel Hempstead, 1993; for a discussion of the difficulties associated with psychometric measurement across cultures.

As well as our own searches, including BIDS, Psyclit and Medline, additional literature searches were carried out by the RCGP and the Kings Fund Centre. Even so, this is not an exhaustive review. It is intended to be of practical assistance to those involved in the increasing amount of research, much of which is small-scale and the result of local initiatives, in this field. Neither is this the first re- view of this type. However, those produced so far have infrequently had a U.K. general practice empha- sis. Also this is an area where the literature is burgeoning and ‘update’ reviews are by no means redundant.

User input to the services which provide health care is being increasingly emphasised [l], whether motivated by a perceived need to democratise the health services, “counteracting the powerful interests of the professions and the state”, or by a wish to stress the interests of the patient as a consumer; “the emphasis is placed on consumer sovereignty and the supply of health care is expected to respond directly to patients preferences and demands” [2, p. 9271. In 1987, through the publication of its white paper “Promoting Better Health”, the government “de- clared its intention of making primary health care services more responsive to consumer needs and demands” Williams and Calnan [3, p. 2371. This in- tention is further enshrined in the new contract for general practitioners [4] and in the establishment of Medical Audit Advisory Groups.

Ignoring any conceptual difficulties with the notion of patients as consumers [5], and findings that patients do not all necessarily want to be consumers (many would prefer a relationship with their G.P.

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based on trust [6], efforts to make medicine more patient centered are justifiable on ethical grounds [2].

On a more pragmatic level; the efficacy of medical practice is enhanced by greater patient satisfaction. It has been shown to influence rates of use and rates of compliance, and to be directly associated with thera- peutic outcomes and health status [2, 71. Patient satisfaction is an increasingly useful measure in as- sessing consultations and doctor-patient communi- cation [7]. To the extent that it is “based on patients’ accurate assessments” [8. p. 6371. patient satisfaction provides. potentially. a direct indicator of system performance and a means of choosing between alternative strategies in health care provision [7].

There is, in consequence, a growing research effort and literature on patients’ attitudes to the health care they receive. Unfortunately, a “basic level of good practice has very rarely been achieved in the hundreds of local surveys which have been carried out” [5. p. 2591. There is a need. therefore, to filter some of the data so that “the wheel is not I-e-invented in every locality” [S. p. 2601.

The material itself suggests conclusions in two broad areas: (I) methods by which useful information may be gained regarding patient satisfaction, and (2) I’Ylctors which influence patient satisfaction. as indi- cated by the research to date.

2. DIMENSIONS OF SATISFACTION

It is rare to find the concept of patient satisfaction defined and there has been little clarification of what the term means either to researchers who employ it or respondents who respond to It [91.

Patient satisfaction is frequently discussed as if it

were a unitary concept [IO]. To some extent it is. although liable to individual variation [I I]. However. a single measure of general satisfaction is inadequate as an indicator of where. or how, any changes may be made to the service provided by a general practice, and relevant dimensions of satisfaction in the context of primary health care are becoming apparent.

Attempts to put satisfaction into the context of a theoretical framework include a ‘value-expectancy’ model [l2, 131 whereby satisfaction is defined as “positive evaluations of distinct dimensions of health care” [ 12. p. 5801. Using this model a comparison of expectations, values, entitlement, and perceived oc- currences as predictors of satisfaction, found expec- tations to be the most significant predictor, although expectations, values and perceived occurrences, to- gether, only accounted for 10% explained variance.

Similar frameworks include a ‘fulfillment model’ (satisfaction = rewards desired - rewards received), and a ‘discrepancy model’ (satisfaction = expec- tations - rewards) [IO]. According to Pascoe [l4], most studies implicitly favour the latter although studies in fields other than health care have indicated that the relationship between expectations and satis- faction is by no means straightforward [lo]. However,

the discrepancy between patients’ expectations and their experiences of the clinical encounter have been shown to relate significantly to their satisfaction with the encounter [ 151.

Feletti and colleagues [ 161, comparing expectations (the ‘ideal’ doctor prior to the clinical interview). with outcomes (reported experience of the encounter after- wards) among Australian patients, found five factors to be of significance as predictors of outcome. all but one of which (technical competence) relate to inter- personal qualities: ‘Communication. care and reas- surance’ (which alone accounted for 249/o of the variance), ‘professional attitudes and behaviours’ (So/,), ‘personal confidant of the patient’ (5%). ‘tech- nical competence’ (4%) and ‘generating trust in the physician’ (3%).

Like and Zyzanski [ 171 drew a distinction between patient expectations and patient requests. They iso- lated five request dimensions; ‘medical information’, ‘psychosocial assistance’, ‘therapeutic listening’. ‘gen- eral health advice’, and ‘bio-medical treatment’ and argued that the degree to which requests are fulfilled may be a major determinant of satisfaction. an uncontroversial finding (“I please”).

Brody [I81 drew a further distinction between desires and expectations: although expectations seem related to satisfaction, it is less clear that desires are. Brody found that a congruence between desires and perceived outcome was generally not related to ex- pressed satisfaction.

Focussing on experience rather than cxpcctations of the clinical encounter. Ware and colleagues [ 19,201 proposed eight dimensions to patient satisfaction: ‘art of care’, ‘technical quality of care’, ‘accessibil- ity,‘convenience’. ‘finances’, ‘physical environment’, ‘availability’, ‘continuity’, and ‘efficacy!‘outcomes of care’. As a result of initial research. these were re-ordered into four factors: ‘physician conduct’, ‘availability of services’. ‘continuity/convenience’, and ‘cost’. This model assumes, as some analysts have contended, that “patients frequently do not dis- tinguish between the art and technical aspects of care” [ 171.

Greenfield and Attkisson [21] also include these two notions within one dimension. They found two broad satisfaction factors: (I) ‘Practitioner manner and skill’, which included six core items; practitioner manner, knowledge and competence, general satisfac- tion, ability to listen and understand, thoroughness and confidentiality/respect for rights and; (2) ‘per- ceived outcome’, which included helping relieve symptoms, and maintaining well-being/preventing ill- ness.

Hulka and colleagues [22, 231 focussed on only three dimensions: ‘professional competence’, ‘per- sonal qualities’ and ‘cost/convenience’, but made a fundamental distinction between the art of care (per- sonal qualities) and technical aspects of care (pro- fessional competence).

Lupton [6] also maintained such a distinction and.

Patient views on quality care in general practice 657

in questions asking subjects the qualities of a good doctor, found that 65% gave responses relating to affective (the most frequently referred to category) and 56% to instrumental aspects of care.

The most thorough meta-analysis available [24] categorises 12 elements of patient satisfaction based on the dimensions included in all the work reviewed (although more than half the studies asked about less than four dimensions): ‘Overall satisfaction’, ‘satis- faction with access’ (including convenience, hours, distance, perceived availability, ease of getting ap- pointments), ‘satisfaction with cost’, ‘satisfaction with overall quality’ (including, for example, time spent with provider), ‘satisfaction with humaneness’ (warmth, respect, kindness, willingness to listen, ap- propriate non-verbal behaviours, interpersonal skill), ‘satisfaction with competence’ (technical), ‘satisfac- tion with information provided’, ‘satisfaction with bureaucratic arrangements’ (including time spent waiting), ‘satisfaction with physical facilities’ (aes- thetic and functional capacities, parking etc.), ‘satis- faction with providers attention to psychosocial problems’, ‘ satisfaction with continuity of care’, ‘sat- isfaction with outcome of care’.

The frequency with which each of these areas has been included in studies is given in percentage terms below; n = 221 [24]:

Humaneness 65 Informativeness 50 Overall quality 45

Competence 43 Overall satisfaction 43

Bureaucracy 28 Access 21 cost 18

Facilities 16 Outcome 6

Continuity 4 Attention to psychosocial problems 3

It should be remembered that this does not reflect how important these aspects of care are to patients, simply how often they are included in surveys.

It seems clear that satisfaction is multi-faceted although the extent to which researchers find different dimensions reflects, at least in part, the extent to which they enquire about them. There is also, and encouragingly, considerable overlap between the di- mensions isolated by different studies. Most instru- ments use a general score of satisfaction against which to validate their sub-scales, so an implicit validity in the uni-dimensional concept is evident. Although difficult to delineate, and made more com- plex by variables such as expectation, it is none the less a vernacular term of which patients and prac- titioners have a subjective, and probably not too dissimilar, understanding.

3. METHODS OF ASSESSING PATIENT SATISFACTION

One of the simplest ways of eliciting patient feed- back is the old-fashioned suggestion box. This could almost be regarded as a control condition, a kind of base line against which other methods could be measured. Anecdotal evidence given to the present author would suggest that the response is often very limited (in one busy practice; 14 comments over a period of a month) and tends to consist either of glowing notices or of resentful grudges. Telephone help lines can be a more responsive version of this open invitation for comment [25].

Focus group discussions, diary keeping, and some types of observation have also been employed in health related enquiries [25,26]. For example obser- vation has been used to some effect in residential settings [27], and diary keeping in a ‘day to day’ context [28]. However for the assessment of general practice services they are not necessarily appropriate.

Although “having an eyewitness in the waiting room gives an important insight into the quality of services and facilities seen from the patient’s point of view” [29], observation could often be carried out in the waiting room only.

Fitzpatrick [7] suggests that tape recordings of patients’ accounts of consultations could be played back directly to staff. There are potential problems in terms of fear of disclosure, confidentiality and time. Videotaping consultations might also be a methodo- logically accurate way of assessing their success, and a method of observation which could be less sensitive to researcher bias. Again though such a method is likely to be too costly, time consuming and, quite possibly, anxiety provoking for general recommen- dation.

An observation checklist is included in the ‘Ask the Patient’ pack developed by the College of Health [29]. This, and other ‘informal’ measures are discussed in practical and theoretical terms by McIver [25,26,30].

Surveys

Usually some form of survey is the most appropri- ate structure within which to research patient satis- faction. One fear sometimes expressed about surveys is that they will reveal largescale and demoralising (to providers) levels of dissatisfaction [7]. In fact the reverse tends to be the case. Expressed levels of satisfaction are typically high. NHS patients are often reluctant to be critical of their health care, especially when they are sick or receiving treatment and there- fore in a position of dependency in relation to the system [ 111.

Another concern is that patients are not competent to judge technical ability and base their judgements on other, interpersonal aspects of the consultation. There is evidence though that this is not the case [ 141, particularly if the questionnaire is designed to focus on different specific features of the patient’s experi- ence. For example “patients’ reports of providers

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informa on-giving have repeatedly been found to correlate positively with objective data on infor- mation-giving gathered from taped medical encoun- ters” [8, p. 6421.

Hall and Dornan [8] cite three studies which indi-

cate that patients can judge technical quality of care [3l-331. Whether or not patients are regarded as competent judges of medical care, the fact is that they do make such judgements, which must influence their

perceptions of the encounter. These judgements are, therefore, relevant to research on patient satisfaction.

Surveys produce data of two broad types: quanti- tative (statistical/numerical), most often the product

of a questionnaire, and qualitative (narrative) usually derived from interviews. (Although there is no absol-

ute division, a closely structured interview is simply a questionnaire administered in person. A question- naire can include items which require a narrative response.) There are advantages and disadvantages to both approaches, some of which are general to the methodology, others specific to this particular field of research.

Levois and colleagues [34] found that interview

administration of questionnaires elicited 10% higher satisfaction rates than other methods of adminis-

tration. Mailed out and telephone surveys have been found to have low response rates (40% and 43% respectively). Whether self or interview adminis- tration yields higher response rates is not clear; there is evidence pointing either way [IO]. It is clear,

however, that both methods yield higher response rates than telephone or mailed questionnaires.

The primary advantages to questionnaires, how- ever administered, are the ease, and relatively low cost, of administration and the provision of standard- ised statistical data which can. when a reliable and valid instrument is used, be compared with other samples. They are less subject to researcher bias than interviews. less staff training is required, and anonymity is more easily guaranteed. If well de- signed. they are easily understood and clearly related to satisfaction [7. IO].

However, standardisation glosses over individual

concerns and numerically small (but perhaps clini- cally significant) problems, particularly as the agenda is set by the professional or the researcher rather than by the patient. In addition they can have low response

rates if administered by post. In practice, they also often suffer from a number of

problems: a ceiling effect due to very high reported rates of satisfaction, lack of standardisation and meaningful comparison rates. lack of reliable scales, little evidence of validity for available scales, difficulty in obtaining unbiased samples, and low relevance of data for program management [lo]. These are not necessarily inherent problems, rather they represent inadequacies in the design of specific questionnaires, which can be overcome. and their speed and ease of administration often makes questionnaires the most

practical methodology if their other problems can be avoided [30].

A further practical difficulty in the U.K. is that most of the carefully designed, published instruments are of U.S. origin [35] and have not been adequately piloted in other health systems/cultures.

Interviews can have greater flexibility in covering topics, and greater sensitivity to patients concerns. There is greater potential to establish rapport with interviewees than with questionnaire respondents, and for clarification of ambiguities in either question or response. There is greater respondent adherence and more scope to follow up non-respondents [7]. Whether unstructured or semi-structured the inter- view can provide qualitative data representing actual individual views, rather than aggregated data.

However, interviews are usually more time con- suming than questionnaires, both in terms of admin- istration and of analysis. Sample sizes tend to be smaller, which can lead to the over-representation of individual views, and a higher risk that individual respondents can be identified by those involved in a general practice.

Questionnaires/quantitative methods

One important finding obtained by Hall and Dor- nan [8], which is of particular significance in the present climate (G.P.s being increasingly encouraged to elicit feedback from their patients), is that ‘home- made’ questionnaires indicate on average 10% higher satisfaction than standardised, published instruments using the basic criteria of psychometry. In their survey of over 200 studies, around 75% used ‘home- made’ instruments. There are probably many more which, unpublished, remain inaccessible. The clear implication is that ‘homemade’ instruments are less discerning, making the need for some standardisation all the more urgent.

The importance of using carefully constructed standardised instruments is also emphasised by Fitz- patrick: “Investigators can use such instruments knowing that some basic properties such as reliability and acceptability will have already been established

[also] there may be other data with which their own eventual results can be directly compared” [p. I 1291.

Regarding questionnaire format, some design vari- ables have significant effects on the level of satisfac- tion indicated. The specificity of the questionnaire is one such; an instrument looking at health care in general will find lower levels of satisfaction than one looking at the respondent’s own doctor/treatment [8]. However, questions relating to a particular incident or consultation have been found to yield lower levels of satisfaction than a general enquiry [3]. One study comparing general against specific questions found more variation in the latter [ 141. As Fitzpatrick points out “The more clearly focussed each question, the easier it is to compare satisfaction with the different elements of care” [36, p. I 1301.

Patient views on quality care in general practice 659

The length of a questionnaire also has a significant bearing on reported satisfaction levels, longer ones discerning greater dissatisfaction than short ones (mean number of items = 25 [S]). It is also possible that this broad finding could reflect a greater antipa- thy generated by, rather than discerned by, longer questionnaires.

Sampling. The methodological desirability of ran- dom sampling is usually acknowledged [e.g. 17,21,37]. However, such a procedure is most prac- tical in a household survey [38], and in practice, most primary care research reaches a compromise between a random sample and one that is self-selecting through the patient presenting at the point of contact (“opportunistically sampled” [39]). The sad result of this approach though is the risk that typically unrep- resented groups remain so [38]. Alternative strategies to random sampling which are unlikely to be “seriously flawed” [36] are systematic sampling (e.g. every tenth patient) or quota sampling, based on predetermined variables e.g. age and sex.

Community samples also reflect lower levels of satisfaction than those enrolled ‘on site’ [8], but community members and practice lists only partially overlap. There are also those who express dissatisfac- tion by non-attendance. They can not be expected to provide accurate assessments of actual services, par- ticularly of changes in those services.

Most general practice research samples ‘on site’. This creates the problem that by only asking practice attenders, dissatisfaction which prevents sick people consulting their G.P., or makes them seek other forms of therapy remain unexpressed. Disabled people, for example, are three times more likely to rate their G.P.s service as poor and their carers twice as likely. If researchers “only contact those already in receipt of services then inequities of provision will result” [38].

Williams and Calnan [3] conducted a general popu- lation survey and excluded from their analysis all respondents who had not attended their general practice for over a year. In the context of much of this research, where G.P.s/researchers are going to be primarily seeking data regarding satisfaction with current services, such an exclusion would be appro- priate. In the case of Williams and Calnan’s study this exclusion reduced the sample size from 454 to 357.

Questionnaire items. Basic information regarding patient variables must form some part of a question- naire: age, sex, education, social class, marital status and health status are obvious potential inclusions although it is by no means clear that they all have an impact on satisfaction (see below).

Other ‘commonsense’ considerations need to be applied, particularly if the questionnaire is for self- completion: it needs to be “easy to follow and attractively set out. It is most important to include a simple clear statement of the purpose and use of the questionnaire and explanations of why the person has been selected, how the questionnaire is to be com-

pleted, and what the person is to do with it after its completion”, and should include a statement of confi- dentiality [36].

More problematic are the items relating to satisfac- tion. These may be direct or indirect: the same question may be phrased either way: “How satisfied were you with the explanations offered by your doctor” (direct), or “My doctor offered complete explanations of my medical condition and treat- ment”, agreedisagree (indirect). In fact there is, empirically, little to choose between these two for- mats which were used with approximately equal frequency among the 221 studies reviewed by Hall and Dornan [8].

Some studies [e.g. 401 mix these formats. This is not necessarily problematic as they intercorrelate to a high degree and produce similar satisfaction levels [8]. However there is an important conceptual distinction in that satisfaction is only inferred from the latter approach: the question: “Did the doctor allow the patient to express any emotional feelings, worries or frustrations” [40] doesn’t ask: did the doctor allow enough opportunity for expression of such concerns. There is no real indication that there was satisfaction with the extent to which such communications were made, simply that they were made, if only to a minimal degree.

How questions are scored is also a relevant factor. Carr-Hill and colleagues [41] suggest that likert (graded, e.g. l-7) responses are more sensitive than yes/no responses which may conceal any grievances “less than major” [41, p. 6151. Similarly, summed likert scales are more reliable than individual items, and the wording of some questions must be reversed so that a response acquiescence tendency will not distort results. These are basic tenets of psychometry but lamentably few of the instruments used to assess patient satisfaction have taken these precautions. Furthermore “the levels of satisfaction expressed depend crucially on the way the question is asked . detailed questions will elicit a more differentiated pattern of responses” [36].

One problem with this area of research is that, typically, such high levels of satisfaction are ex- pressed that distortion of statistical analyses through a ‘ceiling effect’ is a real possibility. The closer the average rating is to the maximum, the more relation- ships with other variables are likely to be disguised: “The small magnitudes of many correlates of satisfac- tion . . . could be largely due to restriction of range in the satisfaction measures” [8, p. 6421. The simple inference from this is that the more critical the instrument used, the more useful the information derived from it is likely to be.

An attempt to counteract this problem, and make survey instruments more sensitive, involved using items which assumed an unreasonably high level of satisfaction, e.g. “was there anything at all that could be improved?“, “Were things ever less than perfect here?” [42]. This style of item was found to identify

660 J. f&ES LEWIS

patients who, despite a broad level of satisfaction, felt improvement was possible from those who did not [IO]. This strategy effectively raises the base line of satisfaction measurement.

Some open ended questions are included in many questionnaires and are advisable. at least in the development stage, in that they invite respondents to raise issues not dealt with by re- searcher set items. Although they tend to yield less critical comments than specific questions [9], open ended items reflect the less structured approach of an interview and are a means of introducing qualitative, as well as quantitative, data into a questionnaire.

Compurison qf doctor/patient perspectives. The comparison of lay and professional views of the clinical encounter has considerable intuitive appeal as a means of indicating where patient satisfaction might be raised. Like and Zyzanski [17], for

example, administered questionnaires to both

patients and physicians. The focus of their study was the effect of fulfilment or non-fulfilment of specific patient requests. They found that the patients’ own views regarding request fulfilment were more signifi- cant than the disparity between the doctors’ and the

patients’ views. Rashid and colleagues [40] in the U.K., found

G.P.s to be less satisfied than their patients. This may reflect their greater knowledge of when they fail to meet their own ideal standard. However it may also reflect weaknesses in the instrument used which gave such high levels of satisfaction among patients that it was barely possible for the doctors to be significantly more so.

Studies such as these follow the assumption that areas where patient-practitioner perceptions of the

clinical encounter are at variance may be the areas where dissatisfaction is engendered. This notion was

tested by Brown and Swartz [15] using a technique developed from a marketing instrument [43], and referred to as Gap Analysis. Patients were given questionnaires which contained items relating both to expectations and experience, and overall satisfac- tion scores were also obtained. Physicians were given a similar questionnaire to complete as they thought their patients would complete them.

Each doctor completed one copy of the question- naire, not one copy per patient. This may be seen as a methodological weakness, but often necessary when weighed against the alternative of each doctor completing one questionnaire per patient, which would be prohibitively time consuming and could distort the doctor’s patterns of behaviour and re- sponse. thus confounding the data.

In this case, the differences between client expec- tations and experiences, and the differences between client experiences and the doctor’s perception of those experiences were found to significantly relate to patient satisfaction.

Published instruments

Most of the carefully developed survey instruments are of American origin, and as well as some items being non-transferable to an NHS setting, it is un- clear how the established levels of reliability and validity are influenced by transfer to a similar, but by no means identical, cultural context.

The development of some of these instruments has already been referred to in the discussion of the components of patient satisfaction [14, 17, 19-231, and six are described in a recent publication [35], with sections on the purpose and background of each instrument, administration and acceptability, re- liability and validity, and the settings in which the instruments have been used. Sample layouts are also given. Although potential problems exist with the untested transfer of U.S. instruments to an N.H.S. setting, it has been commented to the present author that one of the instruments [44] has been useful in research focussing specifically on a particular prac- titioner or consultation [45].

‘Consumer satisfaction with primary care‘. Among the instruments developed in the U.K., Williams and Calnan [46] reported on a self-completion, postal questionnaire used with a sample of 454 general practice patients in Kent. The design of the instru- ment was based in part on previous (U.S.) research; Of the four dimensions proposed by Ware and Snyder [20], ‘physician conduct’, ‘availability of ser-

vices’, ‘continuity/convenience’, and ‘cost’, the cost aspect is not so relevant, or is a different issue, in a U.K. G.P. context. The doctor’s conduct, which Ware and Snyder regarded as a single dimension, was modified to accord with the findings of Hulka [47] and of DiMatteo [48]. These researchers had found that patients distinguish clearly between doctors’ technical and interpersonal skills. Williams and Cal- nan’s instrument then examined, as four separate

dimensions, ‘accessibility and availability’, ‘the

doctor-patient relationship’, ‘professional skills and the quality of care’, ‘organisational aspects of care’.

They collected demographic data and questioned general satisfaction and general faith in medicine, and also subscription to private health insurance. The authors took account of other research from the U.K. [9,49-511 and report confidence in the content val- idity and exhaustiveness of their instrument.

Consultation Satisfaction Questionnaire (CSQ), Surgery Satisfaction Questionnaire (SSQ). Baker [52-541 has developed two instruments specifically for use in general practices in the U.K.: one to measure satisfaction with the consultation, the Consultation Satisfaction Questionnaire (CSQ), the other to measure patient satisfaction with the services offered by a general practice as a whole; the Surgery Satisfac- tion Questionnaire (SSQ).

The CSQ, as well as providing a general measure of satisfaction, addresses 3 aspects of satisfaction, derived from previous surveys and discussion with

Patient views on quality care in general practice 661

both patients and professionals. These are: (1) ‘Pro- fessional care’, comprising “the patient’s concerns about the examination, the provision of information about the illness and its treatment by the doctor, agreement with the doctor’s advice and the doctor treating the patient as a person”; (2) ‘Depth of relationship’, involving “the doctor’s intimate knowl- edge of the patient within a relationship and the transmission of very personal information to the doctor”, and; (3) ‘Perceived time’, the patients’ per- ceptions of the length of consultations when related to their own requirements [52, p. 4881. (Risdale and colleagues [55] also found that patients’ dissatisfac- tion increased with shorter consultations.)

with the CSQ/SSQ format is the availability of data from other practices for comparison. Such a possi- bility is not provided with the Ask the Patient pack.

Concern is often expressed at the extent to which questionnaires actually tap dimensions of importance to patients. This is certainly a valid criticism in some instances, but the questionnaires reviewed above by Williams and Calnan and Baker, were devised specili- tally with a view to patient, rather than professional or political, concerns [2,52-541 (the content of the Ask the Patient questionnaires is similar), and quali- tative assessments were essential initial stages in the development of these instruments.

The SSQ has five principal components distinct from general satisfaction: continuity of care, accessi- bility of premises, availability of doctors, quality of medical care (where it overlaps with the CSQ) and premises.

IntertGewslqualitatiue methods

Initial item generation drew from U.S. data and from discussion with patients and professionals, and early versions contained open-ended questions to identify possible omissions. The final structure was arrived at by factor analysis and the instruments have been assessed and updated in terms of reliability and validity [52-541. The author also provides data from over eighty surgeries in which these instruments have been used, allowing comparative possibilities for workers who generate new data with them.

What essentially differentiates a quantitative from a qualitative approach is the nature of the infor- mation obtained (statistical vs narrative), there is often also an approximate distinction, in terms of administration (self-completion vs oral, face to face). These approaches can, of course, be used in conjunc- tion, an ideal which is often limited by resources, as the collection, by interview, of qualitataive data tends to be more labour intensive and so costlier in human resource terms [26].

At the time of writing they are being tested by independent groups, including an FHSA and a MAAG in Cardiff, Nottinghamshire, Manchester [56] and Sussex. Factor analysis on some of this more recent data has supported the validity of the subscales [45]. The CSQ/SSQ have also been made available to all MAAGs along with a computer programme for their analysis.

Ask the patient. This pack, developed by the Col- lege of Health [29], gives information for prac- titioners about conducting research on patient satisfaction using observation, interview, or question- naire techniques. It includes four questionnaires which, between them, cover similar ground to the CSQ and SSQ; one with a general view of the practice, the second focussing on access and adminis- tration, the third on surgery facilities and the fourth on the care received. Most responses are ‘yes/sometimes/no’ with an additional ‘can’t say’ possibility, and some items are reversed so that the ‘agree’ response registers dissatisfaction rather than satisfaction. Each questionnaire also contains three open ended questions (e.g What do you think we should do to improve the care and treatment at this surgery?), and asks for demographic and other poten- tially relevant data (e.g. How long have you been a patient at this surgery?).

Dun 1381 describes a mixed approach for a commu- nity health survey. Among the methods used were semi-structured interviews: “simple questions were asked in an open-ended way in face to face inter- views”. Several researchers on small scale research initiatives have reported anecdotally to the present author that such an approach, although producing highly personalised data, is capable of yielding infor- mation which is more useful to the provider as it comes in the form of specific suggestions for improve- ment rather than aggregated data of the ‘25% were dissatisfied with . . ’ nature, which can show levels of (dis)satisfaction, but does not offer solutions. Williamson 1571 used semi-structured interviews with mothers to identify both levels of satisfaction and areas of particular concern to this group.

Published instruments

Critical incident technique. The disadvantages to the potentially idiosyncratic nature of interviews can be ameliorated by maintaining some structure. One semi-structured method, of which full descriptions have been published [58], is referred to as Critical Incident Technique (CIT). It was originally used in a hospital Accident and Emergency context [58], but was employed by Gau and colleagues [39] in a general practice setting. This is an interview format intended to allow “patients to talk about the events they consider important”. The results are presented as an inventory of incidents responsible for the patients’ opinions.

In short, many of the concerns registered in this It is stressed [58] that CIT is more than simply a paper are reflected in the design of the ‘Ask the complaints survey. By focussing on incidents which Patient’ pack. Information on scoring and analysis is the patient judges to be critical in forming either also included. One of the most interesting possibilities good, or bad, opinions rather than on the opinions

662 J. REES LEWIS

themselves, results can then be presented in a positive manner which avoids, where possible, threatening criticism. For example, the opinion ‘receptionists are unhelpful’ would not be useful. What is relevant are the specific behaviours that create that impression, or which would dispel it.

Gau’s report makes it clear that the information provided by this method was able to influence the functioning of the practice in which the data was collected: The notification system for smear test results was modified after comments such as: “I never came back for the test results, I think if there is anything wrong they will tell you ” and “I got a word-processed letter-1 needed to go back for another test. The wording really alarmed me. I was convinced I had cancer and they were trying to soft soap me”. Other small but significant changes were implemented: “The high regard patients have for the way some of the partners personally call them in has been adopted by other doctors”, “The dissatisfaction of patients who dislike having trainee G.P.s present during consultation came as a surprise to the partners. Trainees had been sitting in for 15 years” [39, p. 14651.

The sample consisted of 48 patients, small sample size being an inevitable disadvantage to interview surveys, and yet data were generated which reflected patient concerns and which resulted in improvements to the service offered by the practitioners. By classify- ing incidents and constructing an inventory, both qualitative and limited quantitative assessments can be made.

Ask the patient. This pack includes suggestions for a semi-structured interview protocol (the question- naires also contain open-ended, qualitative items). This includes instructions for interviewers with sound methodological advice (“phrase questions in a way that will encourage patients to talk rather than give a yes/no answer”), a sample introductory letter to patients (potential interviewees), a list of topics: patient’s background, access, getting seen, access to care, facilities, services, confidentiality, general infor- mation, in the consulting room, treatment, referrals. most and least appreciated aspects of care, and possible suggestions, with key questions for each.

This is. in effect, a less closely defined version of the CIT with topics drawn from previous general practice research.

Patient participation groups. Patient participation groups offer one structure, with an appropriate de- gree of contact with, but independence of, the prac- tice in which they operate [25], through which the methods reviewed might be employed. Their func- tions include giving patients a say in running a practice, improving doctor-patient communication and feedback, providing a way of dealing with sug- gestions and complaints, promoting health edu- cation, providing a base for voluntary community care, and campaigning for improvements [59].

There is, as yet, little data on their efficacy as a

means of assessing and communicating patient satis- faction. There is also, among such organisations, the possibility of elitism [60] such that the least well served, those typically without a voice, remain so. Patient Participation Groups vary considerably as they are formed for different reasons, with different structures, for sometimes quite limited periods to accomplish a specific task. Results generated from one, therefore, would not necessarily be applicable elsewhere.

4. FACTORS WHICH INFLUENCE PATIENT SATISFACTION: FINDINGS TO DATE

A common superficial finding is that many NHS patients, and patients in other systems of health care, express high general levels of satisfaction with the service provided for them [9,49-51, 61.621. Hall and Dornan’s [24] meta-analysis found average levels of satisfaction of 76% across more than 200 studies.

However, there are bchavioural indicators which suggest that too rosy a picture can be portrayed by superficial satisfaction questionnaires. For example 26% of one sample [62] had used one or more forms of alternative medicine. The increasing use of private health insurance might also be taken to indicate decreasing faith in the health service [2].

Williams and Calnan [3] in a study in the South East of England found 95% of respondents expressed high levels of general satisfaction. But more specific questions revealed dissatisfaction (as was also the case for Carr-Hill and colleagues [40]; specificity in their study being ‘last visit’ as opposed to ‘care in general’), particularly with the doctor-patient re- lationship: 38% felt they could not discuss personal problems with their G.P., 26% felt dissatisfied with the level of information they received, 50% in respect of the specific issue of advice about lifestyle, 25% were dissatisfied with the length of time spent in consultation. Regarding the other dimensions, 38% expressed dissatisfaction with the length of waiting time.

The rank order of all significant correlates with general satisfaction are given below:

1.

2. 3.

4. 5.

6. 7. 8.

9.

10.

G.P. gives enough information 0.64 Like G.P. as a person 0.61 G.P. spends enough time on consultation 0.6 G.P. has good medical skills 0.58 Feeling G.P. did not take problem seriously -0.54 G.P. gives enough advice 0.52 Faith in doctor 0.47 Service available at weekends/holidays 0.35 Speed of consultation re urgent medical problem 0.28 G.P. underprescriber -0.22

(P < 0.001) (P < 0.001)

(P < 0.001) (P < 0.001)

(P < 0.001) (P < 0.001) (P < 0.001)

(P < 0.001)

(P < 0.001) (P < 0.001)

Patient views on quality care in general practice 663

11. G.P. overprescriber -0.21 (P < 0.001) 12. G.P. waiting time too long -0.14 (P < 0.005) 13. G.P. too far away -0.13 (P < 0.007) 14. Number of times G.P.

consulted in last year -0.1 (P < 0.03)

“As these correlations clearly suggest, the specific criteria which yield the highest association with over- all satisfaction scores have less to do with things such as access, availability, level and type of service pro- vision etc. and more to do with the nature and quality of the doctor-patient relationship and the G.P.s interpersonal skills” [3, p. 2401. This is particularly significant given Hall and Dornan’s [24] finding that satisfaction with the provider’s attention to psychoso- cial problems was addressed in only 3% of the studies they reviewed. Even in substantially different cultural contexts and health care systems, the doctors “chair- side manner” is a major correlate of satisfaction [63], as significant in Scarpaci’s (Chilean) data as receipt of tests or medicine.

Williams and Calnan also indicated the importance of this dimension. A stepwise multiple regression revealed four main predictors of patient satisfaction; (1) the giving of information by G.P.s, (2) G.P.s medical skills, (3) G.P.s personal skills (liking the G.P. as a person), (4) faith in doctors. These results further underline the importance of the doctor- patient relationship. Factors like the doctor’s inter- personal skills and technical skills are, from this data, more relevant to patients than factors like access, availability, service provision etc. (concurring with Haigh Smith and Armstrong [37]). Steptoe and col- leagues [64], similarly, found a correlation between satisfaction with care and satisfaction with infor- mation provided.

Frequency of use is also relevant; The acquisition of knowledge and experience by the patient over repeated visits decreases expressed satisfaction [65]. Expectations and experience of health care are of course interacting variables [66] both at a specific level: “tentative expectations [may be] revised in the light of experience of attendance” [2, p. 9301, and a more general level; e.g. “patients’ concern not to waste the doctor’s time” [2, p. 9311.

As some people’s expectations are diffuse and ill-defined, Calnan [2] suggests a more fruitful focus might be people’s motives for seeking care rather than their expectations about that care. Such .an approach has indicated that it is when self diagnosis is difficult, and hence decisions about what action to take, that people visit their G.P. In this case it is uncertainty which primarily sends people to their G.P and satisfaction is “expressed in terms of the ability of the doctor to listen to the patients wishes and to communicate information about what was wrong and what treatment was required” [2, p. 9291.

To what extent this should be technical infor- mation though is a moot point, Steptoe’s findings run contrary to the model whereby “satisfaction depends

on factual understanding” [64, p. 6301. Steptoe resists the conclusion that information should not be pro- vided, and interprets the findings as indicating that “communications [should be] performed sensitively” so that “patients are able to select a level of detail and a degree of confrontation with their condition that they require” [64, p. 6311.

Continuity of care is of some importance [6,59], particularly for older patients [40] although this is not often indicated to be a statistically significant factor. Patients appear to want to be loyal to one doctor, but have a relatively pragmatic approach to switching allegiance. One study found no significant differences in satisfaction with the availability of their doctor, when a full time partner was compared to a part-time job sharing partner [67].

Demographic variables. Only one demographic variable in Williams and Calnan’s study correlated significantly with satisfaction: Age, (r = - 0.23 P < 0.001). This finding concurs with other studies, old people tending to be more satisfied with health care than young [9, 17,49-51,681. Steptoe [64] found a similar relation with cancer patients in relation to care, but not to information given. Again other demographic variables were not significant.

Hall and Dornan [69] confirmed that age was the most consistently significant demographic variable. They suggest a possible explanation in terms of more positive treatment received, as well as the more common explanation in terms of response tendencies (less critical, lower expectations, pre-NHS experience [46]). Hall and Dornan cite two studies which provide some support for this hypothesis [70,71], one of which, a videotape study, found physicians to be “less communicatively dominant, more non-verbally re- sponsive as listeners, and more egalitarian in their interactions with middle-aged and older patients rela- tive to their encounters with younger clients” [71, p. 811. In an assessment of criteria, old people considered seeing the same doctor, being recognised by staff, and having a nurse available to be more important than did young people who placed a higher value on health checks, screening for cancer and immunisation for children [37].

The only other demographic variable significantly associated with satisfaction over several studies was level of education (more educated: less satisfied). This accords with Steptoe’s conclusion that level of infor- mation and satisfaction correlated negatively. (Rashid’s [40] finding that G.P.s were more critical of their own performance than were their patients might also be seen as concordant with this pattern.) Patients’ social status (higher: more satisfied) and marital status (married: more satisfied) were found to have “nearly significant relations” [40, p. 8161.

Patients’ sex appears not to have any consistent relation with satisfaction. Williams and Calnan [46], in the U.K., found women to be less satisfied whereas some American analyses [14, 17, 19,721 found female respondents expressing greater satisfaction. Hall and

664 J. REES LEWIS

Dornan found four studies showing women to be more satisfied, eight showing no difference and five showing men to be more satisfied.

These conflicting results indicate the complexity of cross-cultural comparison, or comparison across different healthcare systems: Hall and Dornan found that men were more satisfied among (American) black or Hispanic samples than women, but this was not the case among white samples. This might also be a reflection of different methodologies, or different questions being asked. Haigh-Smith and Armstrong [37] (in the U.K.) found that many of male and female patients’ most important criteria were the same, but women considered the availability of a woman doctor and cancer screening a higher priority than men who considered waiting time and conveni- ent surgery hours more important than did women.

Other variables considered by Hall and Dornan [69] which showed no significant relation across all the studies they reviewed, were ethnicity, income and family size. Ethnicity however is another area where results from the U.S. may well not be applicable in the U.K. One U.K. study found that “people were generally happy for trained staff other than G.P.s to carry out procedures such as taking blood and giving injections, but those who were older and those from ethnic backgrounds [sic] preferred G.P.s to do these tasks” [68, p. 17321.

Like and Zyzanski [17] suggest that the conflicting results regarding demographic variables may be ac- counted for by: (a) whether patients are being asked about a specific clinical encounter, their own doctor, or doctors in general; (b) whether patients are asked when they are actively seeking health care as opposed to when they are healthy and not seeking care; and (c) where the interview or questionnaire is conducted.

Patients’ psychological d@krences. Psychological differences between patients represent a ubiquitous variable. Steptoe’s subjects, for example, were charac- terised in terms of a “habitual style of coping with stress”; information seeking vs avoidance. Those who were more satisfied with the information they re- ceived were more avoidant in their coping style. Correspondingly. the more informed patients were, the less satisfied they were with the information they were given. They conclude that “patients’ tendencies to cope with stress by seeking out or avoiding infor- mation need to be taken into account” [64, p. 6271. “It may be an over-simplification to assume a linear relationship between information acquisition and sat- isfaction. since the role played by psychological cop- ing responses must be taken into account” [64, p. 63 11.

Other psychological factors have been hypoth- esised to influence patient satisfaction surveys [ 10, 731: self-presentation strategies, willingness to ‘please’ the enquirer by answering positively, reaction to extra attention; the effect of the research itself, and cognitive dissonance (the tendency to justify one’s actions by judging them positively).

Illness status, encitlernent and outcomes. Illness status is an obvious variable; “Where there is con- siderable clinical uncertainty there is also perhaps the greatest potential for dissatisfaction amongst pati- ents” [2, p. 9291. However the effect is not necessarily in the direction that would be assumed: “those who had been the most ill were the most grateful” [68].

Similarly, anecdotal evidence on research amongst the homeless has found that those with least entitle- ment are often those who express most satisfaction with the limited services they do receive. Once again, the importance of expectations is highlighted; those with less entitlement will have lower expectations and may, therefore, be more easily satisfied. This is not a conclusion that can easily be generalised in the light of Dun’s [38] finding that disabled people rate their G.P. services lower than do others. Although inter- related, Linder Pelz [ 12, 131 found expectations rather than entitlement to be the more critical.

Treatment outcome must not be overlooked either as a contributor to patient satisfaction [74, 751. It is, however, one of the least frequently measured vari- ables [8]. This is because patients often make assess- ments before the outcomes are known, particularly in research relating to primary care. This has the advan- tage of getting results relating to satisfaction without an ‘outcome effect’, but misses the changes that inevitably occur over time. Measuring a rise or decline in satisfaction, subsequent to a primary health encounter, is something on which there is little data. Results from two longitudinal studies focussing on the practitioner’s behaviour, which are relevant in this regard [76, 781, are reported below.

Doctor’s behar:iour. Brody [18] found that the doctor’s behaviour had more impact than the congru- ence between desires and perceived outcome, which was generally not related to expressed satisfaction. Also focussing on the doctor’s behaviour. Bertakis [78] questioned patients regarding satisfaction in re- spect of ‘task directed skills’, ‘interpersonal skill’, ‘attentiveness’, ‘partnership’ and ‘emotional support’, of which the two strongest factors were ‘task-directed skill’ and “communication regarding psychosocial topics” on the part of the practitioner.

In a study sampled from among the 4060% of patients presenting with symptoms about which no definite diagnosis would be made, patients were given a ‘positive’ or ‘negative’ consultation, and treatment or placebo treatment [77].

“Two weeks after consultation there was a signifi- cant difference in patient satisfaction between posi- tive and negative groups but not between the treated and untreated groups. Similarly, 64% of those receiv- ing a positive consultation got better, compared with 39% of those who received a negative consultation . and 53% of those treated got better compared with 50% of those not treated” [77, p. 12001. The positive consultation involved a firmly expressed di- agnosis and confident favourable prognosis, and this behavioural style was more effective than, not only

Patient views on quality care in general practice 665

the negative consultation, but also the medicinal technical interventions; examinations, tests, medi-

placebo. cations, and non-drug therapy, were not. Although striking, the generahsabihty of these

results could be questioned. Only one doctor was involved and results may well differ from one prac- titioner to another. There is also the potential prob- lem that 36% of those told that they would be better in a few days were not. As well as treading thin ethical ice, this may be considered likely to have an effect on the doctor’s credibility in the future.

Burgoon and colleagues [82], starting from the premise that effective communication between doctor and patient is a pre-requisite to patient satisfaction, attempted to focus on aspects of communication style and found that “more expressions of receptivity, immediacy, composure, similarity, and formality and less dominance by the physician were associated with

greater patient satisfaction” [82]. Savage and Armstrong [76] measured patients’

satisfaction with two behavioural styles on the part of their practitioner, which they termed a directing style and a sharing style. “Patients who had the directing style of consultation reported significantly higher levels of satisfaction on almost all outcome measures” [76, p. 3011. This was particularly the case for patients with physical problems and for patients who received a prescription. They conclude that their data can be interpreted as supporting the assertion [79] that authoritarianism, paternalism, and certainty are elements of the doctor’s style that satisfy patients most. There are limitations to this conclusion how- ever, as there were no significant differences in satis- faction between the two consultation styles when the consultations were longer, when the main treatment was advice, and among patients with psychological or chronic problems.

An analysis [83] of 41 studies of patient satisfaction in relation to doctors’ behaviour, found “patient satisfaction was related to the amount of information

given by providers, greater technical and interper- sonal competence, more partnership building, more

social conversation, more positive and less negative talk, and more communication overall” [78, p. 1761.

Bertakis concludes that “patients are most satisfied by interviews that encourage them to talk about psychosocial issues in an atmosphere characterized by interest and friendliness and the absence of phys- ician domination” [78, p. 1751.

Also, although patients who had experienced a ‘directing’ rather than a ‘sharing’ style of consultation were more likely to report that they had been greatly helped, satisfaction with the doctor in terms of explanation and understanding, as well as the feeling that they had been helped, declined over a week. Pendleton [SO] has suggested that medium and long term attitudes affect satisfaction over a period of time more than does a single encounter with a doctor.

Other results, not measuring change over time, lay considerable emphasis on the doctor’s behaviour, particularly in the interpersonal domain. Twenty- three percent of Cartwright and Anderson’s subjects [50] made criticisms regarding the extent to which the doctor gave explanations to the patient. Much of the American data also emphasises interpersonal qual- ities and the giving of information. There is less evidence for the popularity of the directive physician though. Bertakis and colleagues [78] found patients to be “less satisfied when physicians dominated the interview by talking more or when the emotional tone was characterised by physician dominance” [78, p. 1751. They also found that physician questions about biomedical topics were negatively related to patient satisfaction whereas physician questions about psychosocial topics were positively related to satisfaction. Although their correlations are low, they cite similar findings by Buller and Buller [81].

A dilemma for the experienced practitioner is

presented by one finding that the experience of a practitioner was negatively related to the satisfaction

expressed by the patient with the consultation. Less experienced physicians have been shown to display more technical and interpersonal skill [8]. According to the same review these are among the behaviours which most satisfy patients. Whether this difference in behaviour is due to more recent, or better, training, to extra effort, less busy schedules or practitioners not having yet become cynical or jaded, is unresolved. The behaviour of the doctor is clearly a significant

factor in a number of ways. However the complexity of the data makes clearcut interpretation difficult, and something of which we should be suspicious.

Lay andprofessional divergence. Much of the avail-

able data has suffered from a managerial bias “i.e. a domination by the providers interests and perspec- tive. Questions about the value of medical care and medical procedures as well as questions about the clinical expertise of the practitioners are rarely seen as appropriate” [2, p. 9291. Instead the focus is often on organisational aspects of a service, like access [40].

A more specific analysis [ 181 found that three non-technical interventions; education, stress coun- seling and negotiation, were significantly related to patient satisfaction, whereas patient perceptions of

As quality of care is frequently assessed on dimen- sions which are professionally or even governmen- tally derived rather than on dimensions which

patients themselves consider to be important [37], there is justified concern that much of the research is “modified paternalism” [84] or tokenism [S, 601 whereby “managers and consultants . . continue to consult . about wallpaper and waiting rooms and will avoid the harder issues surrounding treatment priorities, quality of life, and equity of access” [ 11, pp. 73-741. In a study concentrating on the views of mothers on their general practice services, although issues like “ease of access and pleasant waiting facilities were appreciated, it was satisfaction

666 J. REES LEWIS

with the consultation that related significantly to satisfaction with the service overall” [57].

Haigh-Smith and Armstrong [37] assessed the differing foci of governmental and lay criteria in a general practice setting. Patients compared criteria provided by the government (in the 1987 government white paper ‘Promoting better health’) and by pro- fessionals [85], and criteria elicited from patients in a series of pilot interviews. “The three criteria most highly ranked by all patients were having a doctor who listens, having a doctor who sorts out problems, and usually seeing the same doctor” (all criteria originated by patients). The three least highly valued were health education, being able to change doctor easily, and well decorated and convenient premises (all criteria originated by the government).

They concluded that the best way of maintaining patients’ satisfaction “seems to be to emphasise the traditional if more intangible virtues of good general practice encapsulated in the attentive, competent, and available doctor” [37, p. 4951. The criteria assessed in this study are given below in order of patients’ priority.

1. Doctor listens 2. Doctor sorts out problems 3. Usually same doctor 4. Appointment within two days 5. Regular screening for cancer 6. Health checks for adults 7. Staff friendly 8. Tests at Surgery 9. Staff know me

10. Doctor goes on courses Il. Waiting time < 20 min 12. Small place 13. Nurse on premises 14. Woman doctor available 15. Health checks for children 16. Convenient surgery times 17. Every child immunised 18. Health education 19. Change doctor easily 20. Well decorated premises

(P) = Patient generated items

09 (P) (P) (P) (G) ((3 m (P) P) (G) m m (P) ((3 ((3 ((3 ((3 ((3 (G) ((3

(G) = Government generated items

Martin and colleagues [86] concluded that there was a “wide divergence between doctors and patients about how ill the patient is [patients considering themselves more ill both before and after consul- tation than did doctors], the cause and nature of the problem [largely behavioural as far as doctors were concerned but largely environmental from the patients’ point of view, as Herzlich and Pierret [87] have described in France], and the content of the consultation [doctors thought they had listened and offered support and advice more than did patients]“[86]. This divergence emphasises the gap between doctors’ and patients’ perceptions. “The doctors participating in this project clearly need to

study and adjust their consultation styles to commu- nicate better with their patients” [86, p. 2921.

Rashid and colleagues [40] also directly compared patients’ and doctors’ satisfaction with general prac- tice consultations. They found that doctors and patients significantly disagreed (with the doctors being more critical) about the doctors ability to assess and put the patients at ease. to offer advice on treatment, to allow expression of emotional feelings, and about the overall benefit that the patients gained from the consultation.

Dun reports on an urban community health survey which found that “lay and professional viewpoints are radically different-in some cases reversed” [38]. Dun concludes that the lay definitions of health, and what affects it, are so broad that to satisfy them is a task “beyond the scope of the NHS alone”. Without partnerships between health professionals, citizens, local authorities and housing bodies “NHS reforms will meet only professional and lay criteria”. Such a conclusion is too pessimistic in the context of the present paper where the focus is on the extent to which G.P.s can make improvements within their area of remit.

5. CONCLUSIONS

This report is being prepared in the context of a C.H.C. driven project which aims to assess the most effective methods of indicating what patients perceive to be quality care in general practice. Such methods should accurately reflect patients’ concerns in a man- ner which is useful to general practitioners and to practice managers. To this end a few final comments will be made on some of the available instruments and methodologies, and on what have been indicated by research to date to be factors which influence patient satisfaction, and which are therefore relevant in the interpretation of data produced with such methods.

Instruments and methodologies

Data on patient satisfaction may be of two broad types: quantitative and qualitative. The former is most often survey data gathered in a questionnaire format, the latter, most commonly interview data. Both forms of data collection have advantages and disadvantages. There are particular formats though, of both types, for which attempts have been made to reduce the disadvantages. Only instruments designed specifically for use in a U.K. general practice setting are referred to below. For other published question- naires of U.S. origin see Wilkin et al. [35].

Consultation Satisfaction Questionnaire (CSQ) and Surgery Satisfaction Questionnaire (SSQ) [52-541. Two questionnaires, the former focussing on the consultation itself, the latter on other aspects of the service provided by a practice. These are relatively short, easily understood and quick to complete. Each question is answered on a five point scale, which is

Patient views on quality care in general practice 667

more discriminating than yes/no responses. These likert scores sum for form four and six dimensions respectively, again a more robust method than simply using single scores. The questionnaires contain re-

versed items, to counter response bias, and ‘maximal- ist’ items (e.g. I am totally satisfied with my doctor) to avoid a ceiling effect.

Consumer Satisfaction with Primary Care [3,46]. A much longer questionnaire, more likely to require interview administration, but more thorough in ob- taining, for example, data about patients’ reasons for their visit to the practice. This yields more infor- mation but involves more work to score and analyse than the CSQ and the SSQ. Like them it has been designed with concern for patients’ own criteria and for basic psychometric standards.

This instrument would give more complex data, and would be more time consuming and/or expensive to administer. However the dimensions isolated and measured by the designers of both instruments over- lap considerably (which is itself some evidence for their validity).

Critical Incident Technique (UT) l-981. An interview based technique, providing narrative rather than statistical data. Such a method would use smaller samples and be more expensive in human resource terms than a questionnaire based survey, but the extent to which the interview is structured, i.e. the focus on actions and events rather than simply opinions, yields specific suggestions which have been found valuable in previous research.

Ask the patient. A pack developed by the College of Health [29] with information for practitioners about conducting research on patient satisfaction using observation, interview, or questionnaire tech- niques. The four questionnaires, between them, cover similar ground to the CSQ and SSQ. Most responses are 3 point likerts, and some items are reversed so that the ‘agree’ response registers dissatisfaction rather than satisfaction. Each questionnaire also con- tains open ended questions, and asks for demo- graphic and other potentially relevant data.

The interview format is not dissimilar to the CIT. The CIT is more structured and is explained in greater detail, assisting the analysis of the interviews and report writing. However the topic areas in the Ask the Patient pack are selected specifically for use in general practices. It would be quite possible to use the CIT with the topics from the Ask the Patient pack, which reflect both management and patient concerns, or another list of topics relevant to a particular piece of research.

Factors which influence patient satisfaction

One can question the efficacy of interventions based on the results of patient satisfaction research. Middleton cites evidence that the 20% or so of patients who express dissatisfaction, “remain dissa- tisfied following improvements made as a result of consumer surveys” [88, p. 3481. That this is now a

relatively old finding [89] begs the question: are health providers more responsive to the views of patients in the current consumerist zeitgeist, to the extent that patients actually modify their attitudes?

More recent evidence indicates that patient satis- faction is the only one of four outcomes (self-reported health status, disability and medical costs were the other three) that can be influenced by quality primary care [90]. If this is the case, then factors effecting patient satisfaction, and patient notions of what quality in primary care is, must be increasingly emphasised, not least because they mediate compli- ance and well-being (healing).

A few of the relevant variables can be predicted with some confidence to the implicated in patient attitudes. Age for example; older patients tend to express higher satisfaction, younger people are more concerned with the provision of screening, health checks and immunisation for children. Men and women, although agreeing in the primary importance of having a doctor who listens and who sorts out problems, also emphasise, respectively, convenience and screening programmes [37].

More experienced, better informed and better edu- cated patients often express less satisfaction. This is not always significant, and also involves interacting variables such as expectations and entitlement, which must also interact with ethnicity as a demographic variable.

Undoubtedly of both statistical and clinical signifi- cance though, is the practitioner’s behaviour: “From a theoretical point of view, the evidence supports the arguments of those who have highlighted the signifi- cance of the social and psychological elements in the therapeutic relationships between health pro- fessionals and their clients” [46, p. 7151.

Findings to date indicate that “satisfaction is re- lated to the affective quality of the provider’s manner, the amount of information conveyed by the provider, the provider’s technical and interpersonal skill, and the length of the medical visit” [8]. These are con- clusions from a meta-analytical study using data from many, mainly U.S., sources. Specific U.K. studies find considerable common ground: Carr-Hill [41] found patients emphasising the doctor-patient re- lationship, the discussion of personal problems, ad- vice, waiting times and length of consultation, Williams and Calnan [3] isolated G.P.‘s information giving, medical skills and personal skills as distinct factors, Baker [52-541 isolated similar factors.

People are driven by uncertainty to see their doctor and a requirement for information is high on their agenda. How this information is imparted though is also of considerable importance. However there are anomolous results in this regard, with some studies indicating patients prefer a more affiliative style and others that they prefer a more directive style. There is also evidence, of course, that there are some patients who prefer one manner, and others who prefer the other. As well as differences in consultation

668 J. REES LEWIS

length and presenting problems, these findings may represent cultural (U.S. vs U.K.) or individual (infor- mation seeking vs avoidant) differences. The former possibility exemplifies the potential confounds in- volved in the transfer of instruments designed in one health care system, to another.

Patients value technical and interpersonal skills in their doctor. Among the latter must be a sensitivity to which patients require a doctor with a directive style, and which want information presented in more affiliative manner, which want their social or personal problems introducing into the consultation and which are more concerned with a convenient appoint- ment and some simple instructions. Whatever the practitioner’s consulting ‘style’, or the level of infor- mation imparted nearly all studies emphasise com- munication as one of the aspects of a consultation most indicative of quality care.

How this communication is achieved must depend on the nature of the problem, and the patient’s perception of it, as well as the interacting variables listed above, and more. Given the complexities of the limited available data it must be concluded that, at least for the time being, much of this practitioner’s skill must be intuitive.

This is by no means a new conclusion; it has been referred to as the art of medicine. bedside manner [91]. It is ironic that its importance seems at times to be overlooked, both at a professional level (it has been shown to be the inexperienced doctor who exhibits more of the appropriate behaviours), and at a governmental level; “The objectives of the white paper (Working for Patients) currently ignore perhaps the most crucial aspect of primary care: the time doctors can spend in listening to and counselling their patients”’ [3, p. 2411. Not only is this an aspect of care which has a bearing on health outcomes and compliance (as well as directly on satisfaction). it also appears to be the aspect of care most consistently demanded by the consumer, at least as far as has been indicated by research to date within the market.

It has been argued that patients do not distinguish technical and “art” aspects of care [17]. Perhaps the distinction drawn in the research is too dichotomous. In fact communicative and interpersonal skills are technical skills, and the practitioner who lacks them could be said to be lacking in technique, just as a teaching institution that neglects them could be said to be giving inadequate technical training. They are perhaps the least emphasised and most marketable tools available to the general practitioner. Also, given that the faith which patients want to feel in their doctor [6] represents a substantial, but free, resource, these tools are cost effective and therefore warrant greater governmental as well as professional concern.

Acknon,ledgements-This review was prepared as part of a project supervised by MS V. Williamson. Department of Community Studies, University of Brighton. Her support and advice, along with that of all steering group members. is gratefully acknowledged. JRL.

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