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Patients Experiences of Healthcare

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RESEARCH

Patients’ experiences of their


healthcare in relation to their
expectations and satisfaction: a
population survey
Ann Bowling1 • Gene Rowe2 • Martin McKee3
1
Faculty of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK
2
Gene Rowe Evaluations, Norwich NR2 3HT, UK
3
European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London WC1
WC1E 7HT, UK
Correspondence to: Ann Bowling. Email: a.bowling@soton.ac.uk

DECLARATIONS Summary
Competing interests Objectives To investigate patients’ experiences of health services, and
None declared how these related to what they had expected to receive, and satisfaction
with their care.
Funding
This project was Design Surveys of patients before and after their consultations in
funded by the NHS general practice and hospital outpatients departments.
R&D Programme
Setting Greater London and Essex
Health Technology
Assessment (HTA) Participants In total, 833 patients attending 21 hospitals (434 patients;
Programme; project 52%) and 22 general practices (399 patients; 49%) across Greater London
number: 07/58/01. and Essex sampled in clinics and a population survey.
The views and
Main outcome measures Patient expectations of care, patient
opinions expressed
satisfaction.
therein are those of
the authors and do Results Compared with younger people, and those in black and ethnic
not necessarily minority groups, older people (aged 65+) and White British people had
reflect those of the significantly higher overall realistic expectations of their care ( pre-visit
Department of realistic expectations score: age 60+: mean 53.26 [standard deviation
Health. The funding 13.73]; age <60: 56.20 [15.17]; White British: 54.41 [13.50]; Black and
body has consented other ethnic groups: 56.90 [16.15]) and greater satisfaction
to this publication post-consultation (satisfaction score age 60+: 1.71 [0.80]; age <60: 1.97
and mandates open [0.97]; White British: 1.79 [0.89]; Black and other ethnic groups: 2.01 [0.95]).
access publication. Pre-visit ideal and realistic expectations of care was not significantly
The sponsors played associated with patient satisfaction, although met expectations
no role in the design, ( post-visit experiences) were. Elements of these which was predictive of
execution, analysis, satisfaction were communication with the doctor, information conveyed
interpretation and and clinical outcomes. Factors associated with satisfaction included
writing of the study having a sense of control over one’s life, being older, female,
White British and attending general practice, compared with hospital
Ethical approval outpatient clinics.
This study was
approved by Norfolk Conclusions It is the ability of the system to meet patients’
expectations in respect of the emotional and human features of the

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Journal of the Royal Society of Medicine

and Norwich LREC consultation, and the clinical outcomes, that matter most to people. This
and London MREC research also questions prevailing stereotypes of older age: it is not the
case that older patients are more satisfied with their care because their
Guarantor
expectations are lower. In fact, they are higher, but they believe that they
AB
are being met.
Contributorship
AB, a social
Introduction factors, their understanding of the financial press-
scientist, and GR,
ures on the health service and media coverage of
psychologist,
In this paper we describe research on patients’ its performance. But how do patients’ character-
obtained the funding experiences of health services, and how these istics influence their expectations, and do their
for, and related to what they had expected to receive, and expectations affect their satisfaction with the ser-
co-managed, the their satisfaction with their care. English health vices they receive?
research presented ministers have repeatedly expressed their commit- There are many widely held beliefs, supported
here, and drafted ment to a ‘patient-centred NHS’,1 with Andrew to greater or lesser degrees by empirical evidence.
early versions of this Lansley speaking of his determination to put One is that older people, many of whom will have
paper. Both had patients ‘first’,2 ‘at the heart of care/everything spent part of their lives in more austere conditions,
access to the raw the NHS does’3,4 and ‘in the driving seat’.5 The may have lower expectations and simply be grate-
data. MM, a
2012 Health and Social Care bill has been pre- ful for what they receive, while younger people,
sented as a means for patients, advised by their whose life experiences have been shaped by the
specialist in
GPs, to decide who treats them and how. They consumer revolution and instantaneous gratifica-
European public
will be helped by greatly enhanced information tion, may be much more demanding. The expec-
health wrote the final
on the performance of providers, including the tations of individuals from ethnic minority
draft of this paper, experiences of those patients whom they have populations who were born abroad may be
with AB, and MM treated previously. shaped by having grown up in very poor
provided the policy Patient satisfaction is defined here in terms of countries. But are these any more than stereotypi-
context. The source patients’ evaluations of what happened during cal assumptions? Next we describe what we found
used was the Health their healthcare (i.e. evaluations of their ‘experi- when we asked patients not only about their
Technology ences’ of healthcare). Patients’ experiences are experiences of receiving healthcare but also how
Assessment (HTA) their direct, personal observations of their health- this related to what they had expected of the
report on this topic,7 care. Patients’ expectations have been defined as service they received, both in terms of what it
plus additional
the anticipation that given events are likely to should be like in ideal circumstances and what
occur during, or as an outcome of, healthcare. they realistically expected it to be like.
analyses (odds
Thus, what people expect to receive from their
ratios) undertaken by
healthcare, compared with their observations of Objectives
AB for this paper
what they received in practice (‘experiences’), are
Acknowledgements potentially important in influencing patients’ The objectives of the analyses were to investigate
We thank the
evaluations of their care (‘satisfaction’).6,7 It is patients’ experiences of health services, and how
often argued that an excess of perceived delivery these related to what they had expected to
patients who
(e.g. of healthcare) over what is hoped for, antici- receive, and satisfaction with their care.
participated in the
pated or expected leads to increased satisfaction,
study and their
and conversely, that unmet expectations lead to Methods
doctors and clinic increased dissatisfaction.6,7
staff, especially Dr However, expectations have at least two The study design was based on surveys of patients
Richard Pearson and elements.6 The first relates to what they would before and after their consultations in general
Dr Ameet Bakhi, for expect in ideal circumstances, in other words practice and hospital outpatients clinics.
facilitating outpatient what they feel should be capable of being pro-
recruitment. We also vided in a rich industrialized country. The
second reflects what we might term realistic Sample size and selection
thank Ethnifocus and
their Ethnibus expectations, or what they actually expected to Sample sizes aimed for were a minimum of 100
happen, which will be shaped by, among other interviews and 500 self-completed questionnaires

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Surveying patients’ experiences of their healthcare

interviewers, Katie (sufficient for assessments of interview bias patients in diverse ethnic groups. The question-
O’Donnell, Laura and multivariable analyses). The large samples naires were given by interviewers to eligible
White and Lesley needed, within the study timetable, required two respondents to self-complete (those identified as
Williamson for the methods of sampling: a convenience sample of having a GP or hospital outpatient appointment
fieldwork, Corinne clinic patients waiting to see their doctors in out- within four weeks). Interviewers asked them to
Ward for study patients or primary care, and a population complete the pre-visit self-administration ques-
administration,
survey screen to identify and include patients tionnaire immediately before their clinic visit,
with a pending outpatient or GP appointment. and the post-visit questionnaire immediately after-
Heather Leishman of
Patients were not randomly sampled, requiring wards. The interviewers revisited them within a
Norfolk and
caution when interpreting sample estimates. week of the clinic visit and collected the question-
Waveney PCT
naires. Response could be calculated for the Ethni-
Research Network bus survey: 1413 London (inner and outer)
for her help liaising households were contacted, of which 318 were
The clinic patient surveys
with local practices eligible (had a hospital/GP appointment within
Two UK hospital outpatient clinics (general medi-
and Mable Saili of 4 weeks), 255 agreed to participate and completed
cine and cardiology) and six primary care centres
North Central both questionnaires (80% response rate) and 63
participated in the study. Waiting clinic patients
London Research refused. The Ethnibus responders represented a
were approached by a member of the research
Network, for further 19 hospitals and 16 primary care centres.
team and invited to participate. Patients were
valuable help with asked to sign a consent form if willing to partici-
facilitating honorary pate, to complete the pre-visit questionnaire
contracts. We also while waiting to consult the doctor, and the post- The questionnaires
thank Sally Brearley, visit questionnaire afterwards. They were asked We developed two questionnaires, the first was
who represented to return them to the researcher in the clinic administered to patients in advance of a medical
patients’ groups, for waiting area. They were given freepost envelopes consultation, to explore patients’ (a) ideal and (b)
her valuable to return them in if they failed to complete them realistic expectations in relation to the same sets
feedback on the
at the clinic, and asked to return them within a of expectation items, the second was administered
week. The sample is regarded as a convenience after they had completed the consultation (within
questionnaires and
sample because we had no access to a sampling a week of the clinic visit), and asked patients to
design
frame as full clinic lists were not accessible to rate their experiences of these same expectation
Reviewer us (due to patient confidentiality), it was easy items, in order to measure whether their expec-
Richard Baker to miss attending patients (especially as some tations for these items, had been met. Thus
patients go to different waiting areas or corridors, against each expectation item, patients were
and some go off with nurses to be weighed, or for asked to rate their:
urine tests on arrival), and we did not have their
personal details if they took the consent form Pre-visit:
away with the questionnaires. Thus clinic site
response rates could not be calculated. (1) Ideal hopes about what would happen during
the consultation
(2) Realistic expectations of what would happen
The population patient surveys (‘in reality’)

This was conducted in Greater London by Ethnic- Post-visit:


focus, based on systematic random sampling of
postal sectors, by concentration of ethnic group; (1) Actual experiences (to measure expectations
then a focused enumeration procedure ensuring met).
the representation of people in ethnic minority
groups as well as White British. It involves inter- This post-consultation questionnaire also included
viewers asking at main sample address about eli- a question asking respondents to rate their overall
gibility of those living at the address, to the left satisfaction with the consultation, on a 5-point
and at the addresses to the right. The advantage Likert rating scale from ‘Very satisfied’ to ‘Not
of this method is to ensure representation of very satisfied’.7 A longer, item-specific satisfaction

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Journal of the Royal Society of Medicine

scale was not used given the length of the expec- were White British); 56% were home owners
tations scales, and the additional patient burden (55% in GP sample and 58% in hospital sample).
this would have imposed. These questionnaires, Patients recruited from clinics and from the Ethni-
which are publically available, were developed bus survey were similar in their sociodemo-
on the basis of a structured literature review and graphic circumstances and their questionnaire
qualitative research to understand what patients responses.
considered important, and were piloted.7 The 27 Results are summarized in Supplementary
item-statements (Box 1 which is available online Tables S1 – S3 (available online at Appendix 2:
at available online at Appendix 1: http://jrsm. http://jrsm.rsmjournals.com/lookup/suppl/
rsmjournals.com/lookup/suppl/doi:10.1258/jrsm. doi:10.1258/jrsm.2012.120147/-/DC2). They are
2012.130147/-/DC1)) were grouped into six sub- disaggregated by age (under 60 versus 60 and
scales addressing the physical environment, above) and ethnicity (white British versus black
finding their way around, communication with and minority ethnic groups). Results are also pre-
the doctor, the content of the consultation, the sented by site (general practice compared with
information given and the outcome of the consul- hospital patients). There were no differences in
tation. In the pre-consultation questionnaire, items expectations between men and women. Some sig-
were scored on a 5-point scale (strongly agree to nificant differences did, however, emerge when
strongly disagree); in the post-consultation ver- the sample was stratified by age. Although there
sion, five of these items were reduced to ‘yes/no’ was no overall difference in what was expected
to capture whether certain things had happened in ideal circumstances (though older people had
at the time of the clinic visit. One represented higher expectations about the clinical outcome),
the highest expectation and five the lowest, so older people had higher overall expectations in
lower scores reflect greater expectations. The ques- realistic circumstances, and specifically so in
tionnaires also asked about health status, quality terms of finding their way around, communi-
of life, psychological status and a range of socio- cation with the doctor, consultation content and
demographic characteristics. The measures of the information they would receive. There was
expectations met standard criteria for reliability no significant difference in their expectations for
and validity, with a Cronbach’s alpha score the physical environment or treatment outcome.
(internal consistency) greater than 0.70. Although their pre-visit ‘realistic’ expectations
were higher, older people also expressed greater
satisfaction with the consultation once it was
Results over. This was true for all of the elements of care
except for the clinical outcome, which was not sig-
One hundred and twenty-eight patients were nificantly different from that experienced by
interviewed, and the number who self-completed younger people. In this comparison, the consul-
the questionnaires was 705. These 833 patients tation content was scored in terms of what was
were attending 21 hospitals (434 patients; 52%) done; older people reported a fuller consultation.
and 22 general practices (399 patients; 49%) Overall, white British patients had similar
across Greater London and Essex. Of the 833 ‘ideal’ expectations to those from black and
respondents, 59% were women (63% in the GP minority ethnic groups but significantly higher
sample, and 53% in the hospital sample); patients expectations in respect of most of the individual
had a mean age of 51.8 (range 18.62 –95.15, elements (with the exception of the information
standard deviation 18.02). Fourteen percent were conveyed and the clinical outcome). They did
aged 18– 29, 17% 30 – 39, 16% 40 –49, 17% 50– 59, have significantly higher expectations in what
18% 60– 69 and 18% were aged 70+; they were they considered realistic circumstances, although
comparable by sample (e.g. 33% of the GP this was not significant for ease of finding one’s
sample were aged 60+, as were 30% of the hospital way, consultation content or clinical outcome. As
sample). Sixty-two percent were White British, with older people, despite having higher expec-
14% South Asian and the remainder were in tations, white British patients had higher levels
other black and minority ethnic groups: (65% of of satisfaction, although this time there was
the GP sample and 59% of the hospital sample no significant difference in the content of the

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Surveying patients’ experiences of their healthcare

consultation, nor did satisfaction with the infor- dependent variable took the value of 1 where the
mation conveyed or the outcome achieved differ. patient was satisfied or very satisfied and 0 other-
Patients attending general practice had, overall, wise) (Supplementary Table S4 available online
higher expectations than those attending hospital, at Appendix 3: http://jrsm.rsmjournals.com/
especially in regard to the physical environment lookup/suppl/doi:10.1258/jrsm.2012.130147/-/
and communication with the doctor, both in DC3)). As expected, those whose initial expec-
terms of the ideal and what could realistically be tations had been met (‘experiences’) were much
expected. The GP patients had higher ideal and more likely (five-fold) to be satisfied. However,
realistic expectations than hospital patients about the levels of the initial expectations, both ideal
it being easier to get around inside the building, and realistic, were not significantly associated
and that there would be enough space in the with satisfaction. Other factors associated with
waiting room. GP patients had higher realistic satisfaction included having control over one’s
expectations about the site of the consultation life, being older, female and White British, and
being easy to find, clean inside, the doctor treating attending a GP. The latter analysis was repeated
them with respect and dignity; and higher ideal for the individual elements to identify where
expectations about having a choice of doctors meeting expectations were most important.
to consult where more than one was on site Those emerging as individually predictive of sat-
(not included in scaling due to not-applicable isfaction were communication with the doctor,
responses). These differences would be expected where those whose expectations were met were
as GP patients would be more familiar with their over six times as likely to be satisfied with the con-
consultation site (local GP surgery). GP patients sultation (OR 6.77; 95% CI 3.45– 13.29), infor-
were also more likely, than hospital patients, to mation conveyed (OR 1.99; 95% CI 1.19 –3.33)
have their expectations met about the site being and clinical outcomes (OR 2.11, 95% CI 1.31 –
easy to find, finding the doctor: being helpful, 3.42). The other elements did not reach statistical
treating them with respect and dignity, being significance at the 0.05 level.
knowledgeable/understanding about their con-
dition, clear and easy to understand, involving
them in decisions about their treatment, and Discussion
being given full, clear information about how to Principal findings
manage their condition.
Of course, the key question is whether the level This research reported that whether patients’
of one’s prior expectations (and whether they expectations for healthcare were met determines
were met) influence one’s subsequent satisfaction how satisfied they will be with their consultations.
with the consultation. The initial results were The emotional and human features of the consul-
somewhat counter-intuitive, with those whose tation, and the clinical outcomes, mattered most
expectations were higher expressing higher to people. Older patients’ expectations were
satisfaction. To try to understand these results, higher than those of younger patients, and they
we first explored the predictors of having were also more likely to believe that they were
expectations, whether ideal, realistic or met ( post- being met. GPs’ patients were also more likely
consultation ratings of experiences for each expec- than hospital patients overall to have higher
tation item). The level of initial expectations was expectations, and met expectations, for their
not a significant factor; the only factors that were healthcare.
significant were ethnicity, with those who were
white British being more likely to have their expec-
tations met (odds ratio [OR] 1.64; 95% confidence Strengths and limitations of the study
intervals [CI] 1.16 –2.42) and housing tenure, The strengths of the study are that it was under-
where home owners were similarly more likely pinned by a systematically conducted narrative
to have them met than those in rented or other review of the literature, which was conducted
accommodation (OR 1.58; 95% CI 1.07 –2.32). prior to the empirical research presented here,
A second multivariate analysis looked at the as well as qualitative research to ensure that, as
predictors of overall satisfaction (whereby the far as possible, the expectation measures we

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developed, tested and used were thoroughly today are dominated by the baby boomers,
grounded in the literature and patients’ views.7 whose expectations were shaped by the seemingly
The limitations of the study also require consider- limitless possibilities of the 1960s and the massive
ation. As the clinic samples of patients were based growth in consumerism that accompanied it.10
on convenience samples, and it was not possible to Interestingly, they are no different from younger
calculate response rates, and as the Ethnibus people in what they expect in ideal circumstances;
survey patients were not randomly sampled, rather they are less willing to accept lower stan-
sample estimates need to be interpreted with dards in the reality that confronts the NHS. This
caution. The sample of study sites may thus be is consistent with a wealth of other evidence on
atypical in various ways, and the patient respon- how they differ from earlier generations, viewing
dents may not be representative of all ambulatory themselves as engaged in a process of successful
patient populations. Moreover, due to the length and healthy ageing, rather than one of relentless
of the expectations scales, patient satisfaction decline.11,12
was measured using a single global rating ques- Monitoring patients’ satisfaction with the care
tion only, rather than a measurement scale of satis- they receive, along with details of their experi-
faction with specific service items which might ences of care, is now an accepted component of
have been more sensitive.8 quality assurance.8,13 The public, the politicians
who represent them, and the health professionals
and managers responsible for delivering care
will all benefit from information on how satisfied
Comparison with other studies and the
they are with the care they receive, and on
meaning of the study patients’ experiences. This information is essential
A systematically conducted narrative review of to identify those areas where care is suboptimal
the literature was conducted prior to the empirical and to learn from where satisfaction has increased
research presented here. This confirmed the con- so that whatever is responsible can be adopted
ceptually weak and fragmented nature of existing more widely. However, for this information to be
research on expectations.7 This study confirms acted upon, it is necessary to understand how it
classic observational research showing how it is is shaped by patients’ expectations of the care
the ability of the system to meet patients’ expec- they will receive, not least because these have
tations in respect of the emotional and human almost certainly changed over time (as they have
features of the consultation, and the clinical out- with regard to many other aspects of life) and
comes, that matter most to people.9 Other are likely to continue to do so, and because they
elements related to the physical environment may vary within the population.
and the content of the consultation are obviously
important for other reasons, but play less of a
role in the degree of satisfaction expressed by Unanswered questions for future research
patients. What is new is the information that the Qualitative research is needed in order to add
research gives us on how satisfaction is shaped, insight to the findings that older patients’ expec-
or not, by prior expectations. First, it is not what tations for healthcare were higher than younger
patients expect, but rather whether those expec- patients, and they were more likely to believe
tations are met, that determines how satisfied that they were being met.
patients will be with their consultations. Second,
contrary to what is often assumed, it is not the
case that older patients are more satisfied with Conclusions
their care because their expectations are lower. In
fact, they are higher, but they believe that they These findings have implications for health
are being met. This stereotype may owe much to professionals, managers and politicians. Overall,
the perception of older people growing up older people are satisfied with the healthcare
during the Great Depression and the Second they are receiving and as we have shown, this
World War when they faced deep austerity and cannot be dismissed as a consequence of their
multiple deprivations. However, older people lower expectations. Indeed, it chimes with the

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Surveying patients’ experiences of their healthcare

finding that satisfaction with the NHS among the 5 Conservative Party. See http://m.conservatives.com/
News/Speeches/2010/02/Andrew_Lansley_Our_NHS_
general public is now at an all-time high.14 But
our_number_one_priority.aspx (last accessed 9 April 2012)
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delivery of healthcare in England is undergoing patient satisfaction: concepts, theory and evidence. Int J
profound and unprecedented change, with many Qual Health Care 1995;7:127 – 41
7 Bowling A, Rowe G, Lambert N, et al. The measurement of
services facing severe budget cuts.15 It will be
patients’ expectations for health care. Health Technol Assess
essential for those who are delivering care in the 2012;16:30
midst of organizational and, frequently, personal 8 Crow R, Gage H, Hampson S, et al. The measurement of
turbulence, to remain focused on what matters satisfaction with healthcare: implications for practice from
a systematic review of the literature. Health Technol Assess
most for patients, which means most of all effec- 2002;6:1 –244
tive communication, adequate information and 9 Cartwright A, Anderson R. General Practice Revisited: A
good outcomes. Second Study of Patients and their Doctors. London: Tavistock
Publications, 1981
10 Huber J, Skidmore P. The New Old: Why Baby Boomers Won’t
be Pensioned Off. London: Demos, 2003
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1 Department of Health. See http://www.dh.gov.uk/en/ should define it? BMJ 2005;331:1548 – 51
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