What type of general practice do patients prefer? Exploration of practice characteristics influencing patient satisfaction.

BACKGROUND: General practice is currently experiencing a large number of developments. Studies of patient satisfaction are required to guide the changes that many general practitioners are introducing. AIM: A study set out to examine the characteristics of general practices that influence patient satisfaction. METHOD: In 1991-92, a surgery satisfaction questionnaire of demonstrated reliability and validity was administered to 220 patients in each of 89 general practices. A further questionnaire completed by a member of practice staff collected information about practice characteristics including total list size, number, age and sex of practice partners, training status, fundholding status, presence of a practice manager and whether there was a personal list system. Stepwise multiple regression analyses were undertaken to identify those practice characteristics that influenced patient satisfaction. RESULTS: The mean of the response rates of patients completing questionnaires in each practice was 82%. An increasing total list size of patients registered with practices was associated with decreasing levels of general satisfaction and decreased satisfaction with accessibility, availability, continuity of care, medical care and premises. The presence of a personal list system was associated with increased levels of general satisfaction and increased satisfaction with accessibility, availability, continuity of care and medical care. Training practices were associated with decreased levels of general satisfaction and decreased satisfaction with availability and continuity of care. CONCLUSION: The patients of practices in this study preferred smaller practices, non-training practices and practices that had personal list systems. Practice organization should be reviewed in order to ensure that the trend towards larger practices that provide a wider range of services does not lead to a decline in patient satisfaction. General practitioners should have personal list systems and consider the creation of several personal teams within the practice consisting of small numbers of doctors, receptionists and practice nurses.     

Characteristics of practices, general practitioners and patients related to levels of patients'' satisfaction with consultations.

BACKGROUND: Despite interest in the relationship between patient satisfaction and consultation performance, there is little information about how other characteristics of general practitioners, practices and patients influence satisfaction with consultations. AIM: To identify characteristics of patients, practices and general practitioners that influence satisfaction with consultations. METHOD: In 1991-92, a consultation satisfaction questionnaire (CSQ) was administered to 75 patients attending each of the 126 general practitioners in 39 practices. Further questionnaires were used to collect information about the practice (such as total list size, training status, fundholding status and presence of a personal list system) and about the general practitioners (age, sex, whether vocationally trained, a trainer or a trainee, and the number of patients booked in the appointment system per hour). Stepwise multiple regression was undertaken to identify characteristics of patients, practices or general practitioners that influenced satisfaction. RESULTS: The mean of the response rates to the patient questionnaire for each general practitioner was 76.6%, with a standard deviation (SD) of 17.8. Practice characteristics associated with falls in satisfaction were an increasing total list size, the absence of a personal list system and its being a training practice. If more patients were booked in the appointment system per hour, satisfaction with the perceived length of consultations fell. Patient characteristics associated with falls in satisfaction were increased age and an increased proportion of male patients. The only characteristic of general practitioners associated with lower levels of satisfaction was increasing age. The sex of general practitioners did not influence satisfaction. CONCLUSIONS: The findings of this study give further support to the importance of a personal service in determining patient satisfaction in general practice. General Practitioners need to review the organization of practices to ensure an acceptable balance between the requirements of modern clinical care and the wishes of patients. Future studies should take account of the many variables that can influence patient satisfaction.     

A prospective study of the consulting behaviour of older people with knee pain

BACKGROUND: Knee pain is common among older adults but only a minority consult their doctor about it. AIM: To determine predictors of new episodes of consultation in primary care among older people with knee pain. DESIGN OF STUDY: Population-based prospective cohort study linking baseline survey to primary care medical records. SETTING: Three general practices in North Staffordshire, UK. METHOD: Subjects were 1797 people aged > or =50 years who responded to a general population survey, reported knee pain in the previous 12 months and had no record of a knee disorder consultation in the 18 months prior to the survey. The main outcome measure was a record of a knee disorder consultation in the 18 months following the survey. RESULTS: The incidence of a new episode of general practice care was approximately 10% per year. Apart from chronicity (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.1 to 2.1), measures of pain severity were not strong influences on future consultation. No social support (measured by having no partner) increased likelihood of future consultation (OR = 1.3; 95% CI = 1.0 to 1.8). Among those with chronic and severe pain, main predictors were previous experiences of health care (use of non-GP services OR = 1.8; previous knee injury OR = 1.7). Current depression reduced likelihood of consulting about the knee problem (OR = 0.6; 95% CI = 0.3 to 0.9). CONCLUSIONS: Knee pain is common in the older population but a minority consult their doctor about it. Severity of pain and disability is not a strong influence on consultation. For those more severely affected, depression may act as a barrier to healthcare use.     

Provision of, and patient satisfaction with, primary care services in a relatively affluent area and a relatively deprived area of Glasgow.

This paper presents the results of a survey of the structure of general practice in two contrasting areas within Greater Glasgow health board: the south west area had a more deprived social profile at the 1981 census and higher than average all cause and selected major cause standardized mortality ratios than the health board as a whole while the north west area had a more affluent social profile at the 1981 census and lower than average all cause and selected major cause standardized mortality ratios. The general practice survey data gathered in 1989 were supplemented with data from a survey of residents of the localities in three age cohorts carried out in 1987-88, which provided information on use of services, as well as perceived accessibility of and satisfaction with them. Despite the more deprived social and mortality profile of the south west area, and greater use of services, few systematic differences in the structure of general practices were found in the two areas. These findings support other studies which suggest that the stereotype of poorly resourced, low quality primary care in inner city areas may apply in London, but not elsewhere. Respondents in both areas were equally satisfied with services and found them accessible.     

Community and social interventions at a geriatric medical OPD

Health and social services in Ireland tend to be relatively poorly coordinated. Surveys confirm the perceptions of older people with disability that access to and availability of both health and social services are limited. Multi-disciplinary geriatric medical clinics may provide a focus for better utilization and coordination of these services. The purpose of this study was to measure not only the existing service use but also the potential for community and social-care intervention with older people living in the community when using multi-disciplinary geriatric medical clinics. A sample of 60 consecutive patients aged over 65, attending our geriatric medical OPD for the first time, were interviewed using a semistructured questionnaire on the current and potential use of community and social care services. Our service arranged for 229 interventions or referral to services, an average of 3.8 interventions per patient. Ninety-six services were already in place (an average of 1.6 per patient) and 455 services were not applicable, an average of 7.6 per patient. A combined health and social care response is critical to a successful strategy to disease and disability in later life. Although this study describes a relative utilitarian approach to increase community and social care support, it shows there is significant scope to improve uptake of basic community and social care services by a focussed approach to the care needs of older people.     

Patterns of care for the elderly in general practice

Little is known about the care provided for the elderly by general practitioners. This study is based on data from 89 030 consultations with patients of all ages of which 17 771 were with patients over 65 years of age. It was found that general practitioners carry out more follow-up work with their elderly patients than with their younger patients and they make more home visits and referrals to nursing and social services. However, they do less investigative work with elderly patients and the level of referral to consultants is the same for patients of all ages. Considerable variation was found between doctors in the pattern of care provided for older patients. The proportion of elderly patients on the list of a general practitioner had little effect on his overall workload. The implications of these findings for health service research and planning are discussed.     

Continuity of care in general practice: a survey of patients'' views.

BACKGROUND: It is not known how patients value continuity for different health problems. In addition, it is not clear how different types of patients value continuity. It has been argued, for example, that young and healthy individuals have different ideas about continuity from older people with chronic illnesses. More extensive exploration of patients' views and expectations on personal continuity is important as this may help to organise general practice better in the future. AIM: To explore patients' views on continuity of care in general practice and their relations to patient characteristics. DESIGN OF STUDY: Postal questionnaire survey. SETTING: Thirty-five general practices throughout The Netherlands. METHOD: A sample of 25 patients from each practice was sent a questionnaire. RESULTS: The response rate was 644/875 (74%). The percentage of patients feeling that it was important to see their personal doctor varied, from 21% for a splinter in the eye, to 96% for discussing the future when seriousy ill. The main reasons for preference of their own general practitioners (GPs) were the GP's assumed better medical knowledge of the patient and understanding of the personal and family background. Multiple linear regression analysis (GLM) showed that patient characteristics could explain 10% to 12% of the variance in these views on personal continuity. CONCLUSION: The importance that patients attach to continuity of care depends on the seriousness of the conditions/facing them. Patients in The Netherlands desire a high level of personal care for serious conditions. Patient characteristics, such as age, sex, and frequency of visits to the GP influence views on continuity of care only to a minor extent.     

Stroke services in general practice--are they satisfactory?

BACKGROUND: The contribution of general practice and primary care teams to stroke care has received surprisingly little attention despite research evidence on the importance of coordinated care. AIM: To determine general practitioners' (GPs') and their patients' satisfaction with hospital and community services for stroke patients in Grampian Region, Scotland. METHOD: A questionnaire survey of 138 stroke patients and their GPs was carried out six weeks after each patient was discharged home between June 1995 and January 1996. Outcomes measured were GP and patient satisfaction with services, Barthel Index, Hospital Anxiety and Depression scores, London Handicap Score, and Homsat and Hospsat scores (satisfaction with stroke services). RESULTS: Response rates of 95% (131) for GPs and 91% (125) for patients were obtained. GPs and patients were generally satisfied with services. Stroke patients were more likely to have had contact with their GP than with any other service. Adverse comments from GPs focused on problems with hospital discharge letters. At six weeks, patients received an average of 2.5 community services and 1.5 hospital services, but there was wide variation across disability groups. CONCLUSIONS: Levels of satisfaction were high, but the wide range and variation in services used by patients emphasized the complexity of the primary care of stroke patients; the need for coordination, review and effective links with hospital; and the key role of the GP.     

Are specialist mental health services being targeted on the most needy patients? The effects of setting up special services in general practice.

BACKGROUND: Around 25% of patients with psychoses lose contact with specialist psychiatric services, despite the government's policy to focus the efforts of community teams on this group. AIM: To identify patient and practice factors associated with continuing contact and loss of contact with specialist services. METHOD: Cross-sectional comparison was made of patients in and out of specialist contact, through detailed interviews with 102 patients among 26 south west London practices. Associations were sought between contact with specialist services and patient factors (illness severity, social functioning, quality of life, needs for care, and satisfaction with general practitioner [GP] services) and practice factors (size, location, fundholding status, training status, and the presence of mental health professionals on site). RESULTS: Thirty-one (30%) patients were currently out of specialist contact. No significant differences were found between those in and out of contact on any measures of diagnosis or psychiatric history. Those in contact had significantly more symptoms, poorer social functioning, poorer quality of life, and more needs for care. The proportion out of contact was significantly higher in two practices that had employed their own mental health professionals to provides services on site for severe mental illnesses. Two factors remained significant predictors of contact in a logistic regression model: whether or not the patient's practice offered a special service on site, and greater patient needs for care. CONCLUSIONS: Secondary mental health services are being targeted towards the more needy patients. The provision of special services in practices can shift care further away from secondary care while still meeting patients' needs.     

Does diagnosis determine delivery? The Islington study of older people's needs and health care costs

BACKGROUND: Little is known about the factors associated with the receipt of care by older people. This study investigates the use. costs and factors associated with service usage among people aged 65 or older living in inner London. METHOD: A community-based survey, using questionnaires, examined psychiatric and physical morbidity, formal and informal care. The relationships between demographic, pathological features and the costs of health and social care were explored using multivariate regression. RESULTS: A total of 1085 people were interviewed at home of these 18% did not receive any service at all. The total cost of services per week for people with dementia was pound 109, with activity limitation pound 14 and with depression pound 12. The greatest effect of physical limitation was on the receipt of social care. Dementia had the strongest effect on receipt of social care services. Depression increased health care costs to a much greater degree than social care costs. Despite presenting to services, black elders received significantly less health care than other people with the same needs. Older people living alone were more likely to receive social care support and appeared less likely to use health services. CONCLUSIONS: Physical dependency significantly affects both health and social care costs. Increasing cognitive impairment mainly leads to increasing social care costs. Overall costs are increased by physical dependency, dementia, depression, subjective health problems, living alone and are negatively affected by being black.     

Determining priorities for change in primary care: the value of practice-based needs assessment.

BACKGROUND: Primary care is being expected to expand the range of services it provides, and to take on many of the tasks traditionally provided in secondary care. At the same time, general practitioners (GPs) will become increasingly responsible for assessing their patients' health care needs and commissioning care from other providers. This article describes an approach taken in one general practice to meet these difficult challenges. AIM: To examine whether information on health and health care needs, when used as the basis for a priority setting exercise, can provide a useful first step in planning primary care provision within a practice. METHOD: A three-stage process of information-gathering from a number of sources, including continuous data recording of patient contacts and a postal survey of all adults registered with the practice, identification of key findings and discussion of associated issues, and priority setting of proposals for practice development using the nominal group technique. RESULTS: Continuous data recording of patient contacts with GPs and the practice nurse provided data on 4489 GP contacts with 2027 patients, 1000 district nurse contacts with 101 patients, and 361 health visitor contacts with 172 clients. More than 70% of patient records had been computerized, with 600 diagnostic READ codes identified and 11,500 separate entries made. The socioeconomic and health survey questionnaire achieved an 84% response rate. Following the priority-setting exercise, 28 proposed practice developments were identified. These were reduced to a final list of eight. CONCLUSION: A comprehensive method of practice-based needs assessment, when used as the basis for some form of priority setting, has great potential in helping to plan primary care services within a practice. The success of such initiatives will require a substantial investment of resources in primary care and fundamental changes to the way in which primary care is funded.     

Deafness in adults—screening in general practice

A random sample of 1,083 people, drawn from the lists of two practices in Leeds, was used to estimate the prevalence of deafness among adults. A test for deafness (defined as failure to hear 35 decibels at 1000 Hz in one or both ears) using a portable audiometer proved simple to operate with little observer variation. Eight per cent of adults were found to be deaf. The prevalence of deafness increased with age and was lowest in social classes I and II; there was no significant difference between the sexes. Audiometry showed that 17 per cent of those who thought their hearing was abnormal had no recorded loss of hearing using the stated test and that 18 per cent of those who are deaf would be overlooked if the question “Do you think your hearing is normal?” was used for initial screening in general practice. Less than 20 per cent knew of any services or aids for the deaf apart from those available through general practitioners.     

One practice's review of its use of a general practitioner hospital

For a period of six months a record was kept of every attendance at a general practitioner hospital by a patient from a four-partner practice with a list of 10,500 patients.

During the six-month period one in 17 of the practice population was x-rayed; one in 50 attended the physiotherapy department, and the rate for general practitioner surgery consultations was one per person.

I believe that in semi-rural North Yorkshire the general practitioner hospital has a continuing role to play and such a hospital can provide a better and more comprehensive service to patients, and give professional satisfaction and stimulation to the primary health care team.

     

A survey of job satisfaction, sources of stress and psychological symptoms among general practitioners in Leeds.

BACKGROUND: The past seven years have seen rapid changes in general practice in the United Kingdom (UK), commencing with the 1990 contract. During the same period, concern about the health and morale of general practitioners (GPs) has increased and a recruitment crisis has developed. AIM: To determine levels of psychological symptoms, job satisfaction, and subjective ill health in GPs and their relationship to practice characteristics, and to compare levels of job satisfaction since the introduction of the 1990 GP contract with those found before 1990. METHOD: Postal questionnaire survey of all GP principals on the Leeds Health Authority list. The main outcome measures included quantitative measures of practice characteristics, job satisfaction, mental health (General Health Questionnaire), and general physical health. Qualitative statements about work conditions, job satisfaction, and mental health were collected. RESULTS: A total of 285/406 GPs (70%) returned the questionnaires. One hundred and forty-eight (52%) scored 3 or more on the General Health Questionnaire (GHQ-12), which indicates a high level of psychological symptoms. One hundred and sixty GPs (56%) felt that work had affected their recent physical health. Significant associations were found between GHQ-12 scores, total job satisfaction scores, and GPs' perceptions that work had affected their physical health. Problems with physical and mental health were associated with several aspects of workload, including list size, number of sessions worked per week, amount of time spent on call, and use of deputizing services. In the qualitative part of the survey, GPs reported overwork and excessive hours, paperwork and administration, recent National Health Service (NHS) changes, and the 1990 GP contract as the most stressful aspects of their work. CONCLUSIONS: Fifty-two per cent of GPs in Leeds who responded showed high levels of psychological symptoms. Job satisfaction was lower than in a national survey conducted in 1987, and GPs expressed the least satisfaction with their hours, recognition for their work, and rates of pay. Nearly 60% felt that their physical health had been affected by their work. These results point to a need to improve working conditions in primary care and for further research to determine the effect of any such changes.     

A new GP with special interest headache service: observational study

BACKGROUND: There is poor access to neurology services for patients in the community. AIM: To describe the training of GPs with special interest (GPwSI) in headache and the setting up of a GPwSI clinic in general practice, and report on a comparison with the existing neurology service in terms of case severity, patient satisfaction, and cost. DESIGN OF STUDY: New service provision and evaluation by a questionnaire survey. SETTING: General practice and hospital neurology service in inner-city London. METHOD: The intervention involved training GPs as GPwSIs and setting up a GP headache service. A questionnaire survey was conducted, measuring headache impact, satisfaction, and cost estimates. RESULTS: Headache impact was not significantly different between the two groups of patients, referred to hospital and to a GPwSI. Patients were significantly more satisfied with the GPwSI service, particularly that the service was effective in helping to relieve their symptoms (89% versus 76%; adjusted odds ratio=7.7; 95% confidence interval=2.7 to 22.4). The cost per first appointment was estimated to be pound sterling 136, with pound sterling 68 for subsequent contacts. These are lower than costs for neurologist contacts. CONCLUSION: GPwSI services can satisfy the needs of patients with similar headache impact at costs that are lower than those for secondary care services.     

Evaluating a mental health assessment for older people with depressive symptoms in general practice: a randomised controlled trial.

BACKGROUND: There is a lack of evidence on the most effective primary care management of older people with minor depression. AIM: To evaluate a follow-up assessment by the community mental health team (CMHT) for older people with depressive symptoms identified by practice nurses at a health check for people over the age of 75 years. DESIGN OF STUDY: A pragmatic randomised controlled trial. SETTING: A single large general practice in Leicestershire. METHOD: Patients receiving a health check administered by a practice nurse and scoring 5 or more on the 15-item Geriatric Depression Scale (GDS15) were randomised to either follow-up by the CMHT or routine general practitioner (GP) care. The GDS15 score was measured at the subsequent health check 18 months later. RESULTS: Forty-seven patients were randomised to CMHT assessment and 46 to routine GP care. Uptake of the intervention was 72% (n = 34). At the follow-up health check a greater proportion of the control group had improved GDS15 scores (P = 0.08). Following assessment, the CMHT recommended their further involvement in the care of 12 patients and this was authorised by patients' GPs in six cases. CONCLUSIONS: A follow-up mental health assessment by a member of the local CMHT was not effective in improving outcomes for mildly depressed older people. Other than random error possible reasons for this include the length of follow-up and a failure to meet raised expectations among the intervention group. If complex referral procedures do not improve outcomes for this group, then specialist community services should play a more prominent part in the training of practice staff to care for their depressed older patients.     

Changes in patient satisfaction and experience in primary and secondary care: the effect of general practice fundholding.

BACKGROUND: The contributions of patients' opinions to the evaluation of health care is widely acknowledged. This study investigates whether the patients of a fundholding practice perceived any changes in the services offered. AIM: To examine the effect of general practice fundholding on patient satisfaction with both primary and secondary care services. METHOD: In April 1992, questionnaires were sent to 180 patients in each of four second-wave fundholding practices and four non-fundholding practices in the former South East Thames region. This took place before any changes were made in the practices as a result of fundholding. Repeat questionnaires were sent 30 months later. RESULTS: The overall response rate was 70% in 1992 and 66% in 1994/1995. Satisfaction levels were generally high for primary care services and changed little over time. There was no evidence to suggest that fundholding GPs were less inclined to prescribe or refer to secondary care services. Waiting times for the first appointment with a consultant in secondary care had reduced between 1992 and 1994 for patients referred from the fundholding practices. However, there were no differences in the time patients had to wait for subsequent treatments or further investigations. One-fifth of the fundholding patients referred to secondary care were seen by the specialist in their doctor's surgery, and those seen in this setting preferred it. CONCLUSION: Patients perceived no major differences in primary care services over the period between the two surveys. There was some evidence of preferential treatment for patients of fundholding practices, but only in waiting times for the first appointment with the secondary care specialist.     

Patient participation in general practice: who participates?

A postal survey of 4066 men and women aged between 16 and 64 years was carried out in a general practice in Oxfordshire which had a patient participation group, established in 1972. The aim of the survey was to ascertain the knowledge and use of the group among adults aged 16-64 years. The adjusted response rate was 73%. Despite the length of the group's existence only 45% of these patients were aware of it and only 7% had ever attended a meeting. Awareness of the group and sometime attendance were significantly less in men, patients aged between 16 and 29 years, those in social classes 4 and 5, single people and those who smoked. Patients who consulted more than four times per year were more likely to be aware of the group than less frequent consulters. The possible reasons for the unrepresentative nature of the patients attending the group are discussed, together with implications for practice policies and development. Various strategies for making the group more representative are proposed, including advertising within the practice and elsewhere, and the formation of special interest groups for patients with defined medical and social needs, in the hope that this will make the concept of patient participation more relevant.     

A qualitative study of older people''s views of out-of-hours services.

BACKGROUND: Out-of-hours primary care services continues to change with the growth of general practitioner (GP) co-operatives and the more recent development of NHS Direct. While older people are more likely to have increased needs for such services, evidence suggests that they are reluctant users of GP out-of-hours services. AIM: To explore older people's experiences and perceptions of different models of general practice out-of-hours services. DESIGN OF STUDY: Focus group methodology, with qualitative data analysis undertaken using a grounded theory (Framework) approach. SETTING: Thirty people aged between 65 and 81 years old from community groups based in south east London. METHOD: Four focus groups were held, each with between five and 12 participants. Each focus group session lasted 90 minutes and was audiotape-recorded with the permission of the participants. The tapes were transcribed verbatim. RESULTS: Two related themes were identified. First, attitudes to health and healthcare professionals with reference to the use of health services prior to the establishment of the NHS, a stoical attitude towards health, and not wanting to make excessive demands on health services. Second, the experience of out-of-hours care and the perceived barriers to its use, including the use of the telephone and travelling at night. Participants preferred contact with a familiar doctor and were distrustful of telephone advice, particularly from nurses. CONCLUSIONS: Older people appear reluctant to make use of out-of-hours services and are critical of the trend away from out-of-hours care being delivered by a familiar GP. With increasing numbers of older people in the population it is important to consider steps to address their reluctance to use out-of-hours and telephone advice services, particularly those based around less personal models of care.     

Age and sex interaction in reported help seeking in response to chest pain.

BACKGROUND: There is a growing literature suggesting that access to cardiology services is affected by age. However, there is a dearth of studies that have considered age and sex in conjunction. AIM: This study aims to examine the impact of age, and its interaction with sex, on reported healthcare seeking, based on responses to symptom vignettes, in an attempt to standardise symptomatology across all responders. DESIGN OF STUDY: A cross-sectional survey design was utilised. SETTING: Primary care. METHOD: A random sample of 911 individuals, stratified by sex, was selected from one practice in the UK. Participants were invited to state how they would react in response to the chest pain symptoms presented. Patterns of response were examined, by age and sex, using chi2 and logistic regression models. RESULTS: This study identified differences by age and sex in a general practice population in the propensity to seek health care. In particular, men aged 60-69 years and women aged 70 years and over were more likely to report healthcare seeking than younger responders. For example, women aged 70 years and over had over three times greater odds of reporting contact with the GP compared to the reference category. Evidence for an interaction effect between age and sex was observed. CONCLUSION: The results suggest that the inequity that has been demonstrated in access to cardiology services by age is not likely to be due to the patient's illness behaviour as, overall, older people are more likely than younger people to be willing to consult their doctors.