Predicting and comparing patient satisfaction in four different modes of health care across a nation
Introduction
There has been a steadily growing policy interest in the UK in ways in which patients can increase their involvement in the planning, delivery and evaluation of health care, from the demands of voluntary and community activists in the 1970s, through the development of a consumerist agenda in the 1980s and early 1990s, to a more citizen-focussed set of policies in the last few years. The modernisation agenda of stakeholder engagement and inclusiveness of the New Labour Government since 1997 was initially set out in the White Paper ‘The New NHS’ (Department of Health, 1997) and ‘A First Class Service’ (Department of Health, 1998). Subsequent to the devolution of responsibility for health care to the constituent nations of the UK in 1999, each one has developed similar but distinctive policies in relation to making progress with the citizen involvement agenda.
In Scotland, the policy direction was set out initially in ‘Designed to Care’ (Scottish Office, 1997) and since devolution in the Health Plan for Scotland, ‘Our National Health: a plan for action, a plan for change’ (Scottish Executive Health Department, 2000), which place patients as key partners in health and social care development. More recently, ‘Partnership for Care’ (Scottish Executive Health Department, 2003) reinforces this notion by equating the priority of patients’ views with clinical standards and financial performance. In order to inform the Health Plan for Scotland, two commercial polling companies, MORI Scotland and System Three, were commissioned to carry out a survey of public perceptions and experiences (as patients) of the NHS in Scotland (Scottish Executive Central Research Unit, 2001). It is this dataset that forms the basis for the analysis presented here.
Patient evaluation of health services has long been seen as a legitimate and necessary part of the patient involvement project for a variety of reasons, depending in part on the viewpoint of the particular stakeholder group. In the UK some of the earliest work has been in groups that have included academic social scientists concerned with sociological (Cartwright, 1964), psychological (Raphael, 1967) and managerial understandings (Moores & Thompson, 1986); health care professionals in nursing (McGhee, 1961), hospital medicine (Hill, Bird, Hopkins, Lawton, and Wright (1992), hospital surgery (Meredith, Emberton, & Devlin, 1993), and general practice (Baker, 1990); users’ organisations (Jones, Leneman, & Maclean, 1987); and managers and policy makers involved in the policy developments referred to above, beginning with the Royal Commission on the NHS (Gregory, 1978) and accelerated by the recommendations of the Griffiths Report on managing the NHS (Department of Health and Social Security, 1983). The reasons for this high level of interest have been manifold, including pressures to democratise public service provision through greater public accountability (Barnes, 1997; Hogg, 1999), a growth in consumerism in public policy (Avis, Bond, & Arthur, 1995), concerns about treatment concordance (Wright, 1993), professional ethics (Grol, 2001), and the drive to improve the quality of care with respect to treatment outcomes and social acceptability of the processes (Coulter, 1991).
However, the way in which services have been subjected to user evaluation has generally been limited to measures of satisfaction, sometimes labelled subjective indicators, and/or patient reports, believed by some to be objective indicators (Ware, Snyder, Wright, & Davies, 1983; Wensing and Elwyn, 2002). As Crow et al. (2002) make plain, patient satisfaction has been a dominant strand, with their search of 7 electronic databases uncovering more than 270,000 ‘hits’ in articles published mainly in the English language incorporating this theme over the period 1980–1998. Despite the continuing concern and criticism that patient satisfaction is a poorly theorised concept (Williams, Coyle, & Healy, 1998), it has become a major source of feedback to the NHS at the national level in England (Airey et al., 1999) and at lower organisational and professional levels across the UK. The Scottish Executive has pursued a different route, encouraging local surveys while sponsoring an ad hoc, national population survey of the major NHS services.
While a large volume of research has grappled with the meanings and determinants of satisfaction, the growth in routine systems of incorporating patients’ views demands that attention be paid to what might be of value within these measures. This will hold true whether it is based on surveys of the general population for use by policy makers and managers at the system or programme level, or of specific services to indicate where health care practitioners and operational managers might effectively focus their efforts to improve quality in a patient-centred way. Relatively little research has investigated in a deeper analytical way comparisons between services to explore whether patient evaluations, especially by those who use several services within a particular time period, follow similar lines of rationality across services, or whether different contexts provoke divergent criteria. A notable exception is the work of Williams and Calnan (1991), who used a self-completion postal questionnaire to compare the criteria for assessing general practice, community dentistry and inpatient hospital care. Their conclusions were that, while different contexts offer specific and distinct issues of concern to patients, there were common predictors of global satisfaction in all three settings, labelled professional competence and patient-professional relationships, with age offering further explanation for satisfaction. In line with several other scholars (Jenkinson, Coulter, Bruster, Richards, & Chandola, 2002; Thompson, 1986) they also argued for attention to specific dimensions of care rather than the more general, global outcome measures. Nevertheless, while in accord with this view, Fitzpatrick (2002) also sees value in including global questions as a way of identifying the most important issues for health care providers, in addition to the specifics of care.
The increasing interest at the strategic level in population-level surveys of patient satisfaction requires firmer evidence of its value across services and whether the convergence in evaluation exists across a broader range of services in different localities. Given the wide variety of instruments used to measure satisfaction it would also be very useful to identify the common dimensions that patients use in their evaluations in a more robust way. Virtually all measures of satisfaction either exhibit distributional problems of skew and kurtosis, leading to biased estimates of population parameters, or require careful attention to the level of measurement. Thus, techniques that rely on assumptions of interval measurement, such as Pearson's correlation coefficient or multiple regression, require careful handling, especially with relatively small sample sizes, when the questions use ordinal (e.g. Likert) or nominal (yes/no) answer formats.
Therefore, this study was designed to determine the underlying dimensions of patients’ perceptions of quality, as indicators of satisfaction, within the four different public health services of general practice, domiciliary care, outpatient hospital care and inpatient hospital care. The context was set to be within the jurisdiction of one National Health Service, NHS Scotland, where we could be sure of a common policy framework. This would then offer the possibility of exploring the degree of evaluative convergence across services, as well as providing a robust basis for determining some of the likely key explanatory variables of the measures of global satisfaction for each service, as suggested by extant literature. In addition to the expected dimensions, many studies have pointed to the importance to explanation of certain socio-demographic variables, including age, which consistently shows older people as more satisfied (Crow et al., 2002), gender, which is inconclusive as to whether men or women are more satisfied (Crow et al., 2002), education, which tends to show the higher educated as being more critical, although less pronounced in the UK (Sitzia and Wood, 1997), and health status, which generally shows lower satisfaction among those in poorer health (Cohen, 1996; Crow et al., 2002).
Section snippets
Sample
This study provides a secondary analysis of a dataset created from a survey of 3052 adults’ opinions of the NHS in Scotland (Scottish Executive Central Research Unit, 2001), sampled from those aged 16 years and above resident in Scotland. Stratified quota sampling reflected the characteristics of the population regarding age, gender, social class and housing tenure (as a partial proxy for wealth and social class). The quotas were based on the Scottish Household Survey (Scottish Executive
Sample characteristics
Of the 3052 in the total sample3
Discussion
The aim of this investigation was to determine and compare dimensions of patient satisfaction in the four selected services, in a way that would offer statistically robust measures and analyses. In common with Williams and Calnan (1991), we found both divergent dimensions which were specific to the contextual factors of particular services, as expected, and convergent factors across all services. These latter, statistically based dimensions included aspirations for service improvement, and
Acknowledgements
Grateful thanks is given to the Scottish Executive Health Department Analytical Services Division for access to the dataset upon which this investigation has been based. The authors, however, take full responsibility for the views expressed here, including any errors of analysis or interpretation.
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