1 Main Findings
1.1 This report explores variations in the self-reported experiences of different people using GP and out-of-hours health services. The main source of information is the Scottish Patient Experience Survey of GP and Local NHS Services 2011/12. This survey asks GP patients about their experiences of accessing and using GP and local NHS services. The survey was posted to a random sample of people registered with a GP practice in Scotland during November 2011 and 145,569 people responded.
1.2 The analysis examined the relationship between self-reported experiences of patients and a range of patient, GP practice and regional level characteristics. Patient characteristics included gender; age; ethnicity; religion; sexual orientation; deprivation; urban/rural classification; work status; being a carer; health status; day-to-day activity limiting health problems; translation, interpreting and communication support needs; disability status; and how often people contacted their practice in the last year.
1.3 GP practice and regional level characteristics included practice size, the percentage of patients registered at a practice living in deprived areas, as well as differences between practices, Community Health Partnerships (CHPs) and NHS Boards.
Main survey findings
1.4 We published the main survey findings in May 2012 (Scottish Government 2012) and the national report is available at: http://www.scotland.gov.uk/Publications/2012/05/8250/0
1.5 Patients were mainly positive about their experience of consultation with doctors or nurses. At least 90 per cent of patients responded positively to all of the questions about doctors and nurses.
1.6 Overall 89 per cent of patients felt that the care provided by the GP surgery was excellent or good.
1.7 Patients were less positive about their experiences of accessing GP practice services. We found that 75 per cent of patients rated the overall arrangements to see a doctor as excellent or good, while 84 per cent of patients rated the overall arrangements to see a nurse as excellent or good.
1.8 We found there was considerable variation in the results for individual GP practices, particularly when it came to accessing services.
1.9 People were less positive about the care they received from out-of-hours services than from their own GP practice. We found that 72 per cent of patients rated the overall care they received out of hours as excellent or good.
1.10 Our additional analysis aims to identify the causes of variation in the experiences of patients, whether they be patient, GP practice or regional level characteristics.
1.11 We used a statistical modelling technique for the analysis to allow us to take into account all the available factors that have an effect on the likelihood of a patient reporting a positive experience. The advantage of this approach is that it doesn't look at one factor in isolation, which may potentially provide misleading results, but takes into account all factors which may have an effect. The analysis we used attempted to assess the effect of each factor on experiences.
1.12 Our findings add to the growing body of research examining variations in patients' experiences of healthcare provision. Some of the existing research focuses on patient characteristics only, while other studies take into account both patient and wider factors. Our analysis has explored the influence of both patient and non-patients factors which will be useful to service providers and national improvement partners in a variety of ways. As well as assisting service providers in considering the needs of different groups of people in a more informed way, the findings also help to highlight the important role service providers can play in improving the experiences of their patients.
1.13 We found that the factors that had the strongest effects on people's experiences were:
- The GP practice that they were registered with - there was considerable variation between practices, especially when it came to accessing services. There was also considerable variation between practices in people's experiences of doctors and nurses, and in the overall care provided. From Chart 1 it can be seen that 41 per cent of the variation in people's experience of the overall arrangements for getting to see a doctor is explained by the practice they are registered with.
- The size of their GP practice - people reported better experiences at smaller practices. The effect of practice size was greatest when it came to accessing services.
- Age - we found that older patients reported better experiences. The effects of age were greatest for people's experiences of doctors and nurses, and the overall care provided.
- Health status - people with better health status reported better experience. Health status had a similar effect across all areas covered by the survey.
1.14 For out-of-hours services we found that the services which people used had a strong effect on their experience: people had less positive experiences of out-of-hours services provided over the phone. This could be because people may find phone consultations with unfamiliar health care professionals more difficult than face-to-face consultations which often involve familiar primary care staff.
1.15 We also found some differences in people's experiences due to gender, socio-economic status, ethnicity, whether in work or education, being a carer, having a disability. However these differences were less marked. We discuss these effects in the detailed findings section of this report.
Chart 1 Percentage of variation in experience explained by the GP practice for selected questions
1.16 The original findings from the analysis of the national survey found that people were generally positive about local health services, although they were less positive about accessing GP services and out-of-hours services. It also found that there was considerable variation in the experiences of patients from different practices. This analysis aimed to explore the factors which influence variation by looking at patient, GP practice and regional level characteristics.
1.17 Our findings are similar to other studies in that they show that the main factors which influence experience relate to the GP practice itself, size of GP practice (larger practices less positive) and some patient factors such as age (younger patients less positive) and health status (those with poorer health less positive). Differences around gender, socio-economic status, ethnicity, whether in work or education, being a carer, having a disability, were less marked.
1.18 The findings suggest that while some variation can be explained by patient characteristics, other GP practice-related factors also play an important role: patient experience especially around access and staff is strongly influenced by the individual GP practice. This suggests that GP practices have an important role in looking at ways to improve the experiences of their patients in these areas. Given that we found considerable variation between practices across Scotland, one way of doing this would be to learn from other practices.
1.19 Our finding that the size of the GP practice had a strong effect on patient experience is consistent with previous studies which show that smaller practices are associated with higher satisfaction around access and continuity of care (Kontopantelis et al 2010, Campbell et al 2001b). We found that patients in smaller practices were much more positive about their experiences around: being able to get through on the phone; making appointments; and seeing their preferred doctor.
1.20 Looking at the influence of patient characteristics, it is not clear how these differences can be explained, for example whether they can be accounted for by actual differences in the quality of care provided or different cultural expectations between population groups. We found marked differences between younger and older people especially around doctors and nurses and overall care provided. Older patients are generally known to provide more favourable perceptions of care (e.g. Crow et al 2002, Mead and Roland 2009, Campbell et al 2001a, Kontopantelis et al 2010, Lyratzopoulos et al 2012). Given that many of the differences between young and old were particularly marked around GP practice staff and overall care, cultural differences in willingness to report unfavourable assessments might explain some of these differences.
1.21 The other major influencing patient characteristic was self-reported health status, with those reporting poorer health being more negative. This finding is consistent with other studies that have explored the influence of health status (see Crow et al 2002 systematic review, Lyratzopoulos et al 2012). It is difficult to fully explain the differences here. They may be accounted for by the greater complexity of need or greater exposure to health services, increasing chances of having a negative experience. However it does suggest the importance of finding ways to address the needs and expectations of people with poor health.
1.22 Looking at the variations in the experiences of different patient groups is important. It allows service planners to understand and take account of the needs of different communities as well as working towards eliminating discrimination, reducing inequality, protecting human rights and building good relations by breaking down barriers that may be preventing people from accessing the care and services that they need (Equality Act 2010).
1.23 The person-centred ambition of NHSScotland Quality Strategy (Scottish Government 2010) advocates mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making. Such a holistic and individual approach suggests that the individual needs, preferences and values of patients as well as personal group characteristics are important factors to take into account in providing person-centred care. The analysis has shown the importance of understanding the potential effect of group variations. Clearly it is important to avoid making assumptions about patients based on personal group factors, but the findings may assist service providers in considering the needs of different groups of people in a more informed way.
1.24 However, while patient characteristics account for variations in experiences, the analysis has shown the importance of understanding the influence of non-patient factors such as the individual GP practice and size of GP practice. It suggests that individual GP practices can play an important role in looking at ways to improve the experiences of their patients especially around access, continuity of care and staff.
Email: Gregor Boyd