Patients’ experience of primary care: James Mackenzie Lecture 2017

INTERNATIONAL CONTEXT

An increased supply of primary care doctors who are demonstrably valued within their health economy is associated with lower average population mortality, a range of beneficial health outcomes, and with better patient experience of care.¹ The delivery of high-quality patient experience of care is one of three central aims of healthcare systems, and the Commonwealth Fund has recently highlighted the strong position of UK health care in respect of access to care for the population.² The first National Patient Survey (1998) was inaugurated after NHS proposals suggested that patients’ views on quality of care should be taken into account, and the Constitution of the NHS has enshrined the importance of the experience of patients within UK health care.³

MONITORING PATIENT EXPERIENCE

The US-derived Primary Care Assessment Survey⁴ informed the development of GPAQ, the UK’s General Practice Assessment Questionnaire.⁵ From 2006, practices could benefit financially under the UK Quality and Outcomes Framework — around £6000 for an average practice — provided they had developed a written plan around access, had conducted a patient experience survey using an approved instrument (such as GPAQ), and had consecutively surveyed patients attending their practice.

By 2007, the National GP Patient Survey (GPPS) focused on issues relating to appointment availability, routine appointments, telephone access, and continuity of care. Emerging research evidence around the development and use of the survey⁶ provided some confidence to politicians and healthcare planners regarding its potential. Between 2009 and 2011, it was used to reward practices under a ‘pay-for-performance’ scheme. The GPPS continues to inform national policy in the NHS Outcomes Framework,⁷ contributes substantial data supporting Care Quality Commission inspections of practices, and continues to inform discussions around patient experience within the Department of Health.

Our ‘mystery shopper’ research was part of a programme of research investigating the potential of patient experience of care in informing NHS service development. Under research arrangements, across a 1-year period we phoned practices, requesting an appointment.⁸ We compared seven research measures of access with seven measures of access from routine GPPS data. In the 41 practices who took part we found a strong association between research measures and the routine measures. At least in respect of access to appointments, the GPPS appeared to be a valid measure of patients’ experience of care.

WHAT DRIVES PATIENT EXPERIENCE OF GP CARE?

Our research identified a number of key domains that we know are relevant in terms of patients’ experiences of care,⁹ including doctors’ communication, interpersonal aspects of care, availability of appointments, and ease of telephone access. Among all of these, communication with the GP appeared to be the main driver of overall patient satisfaction with care.

In related research,¹⁰ we explored the relationship between the practice’s overall scores on GPPS questions relating to communication, with the scores estimated for individual doctors obtained during surveys of patients following a consultation. Practices with, on average, better scores had doctors who, individually, tended to have good scores overall. However, where practices had lower overall scores, we observed a much wider range of individual performance. Given this, it appears that surveys may provide a useful way of targeting efforts aimed at improving communication among doctors, focusing on practices with lower scores rather than on all practices.

Patients from ethnic minorities often provide overall ratings of doctor–patient communication that are lower than their white British counterparts. In light of this, we investigated how white British and Pakistani people rate communication within simulated GP consultations. We invited age- and sex-matched patients from various ethnic groups to look at and assess standardised video vignettes of simulated consultations.¹¹ Unexpectedly, compared with white British patients, Pakistani patients viewing the same videos on average scored those videos nearly 10 points higher than the white British respondents. It thus appears likely that GPs may disadvantage some of our ethnic minority patients much more than has previously been recognised.

Another area of great interest focused on patients’ experience of telephone triage. We worked with 42 practices, and 21 000 patients. Practices were randomised to deliver GP-led telephone triage, nurse triage, or to continue with their usual care for patients who were seeking same-day appointments with a GP. Overall, we observed an increase in GP workload in the 28 days following a telephone triage consultation of between 33% and 48% when compared with usual care.¹² Where telephone triage was delivered by a GP, we observed a reduction in the number of GP face-to-face appointments conducted, but an overall substantial increase in numbers of contacts with the GP. Where triage was operating, many participants reported better experience of getting through to the practice on the phone, but were pretty neutral in respect of GP-delivered triage. Where nurses were delivering the triage, patients’ experience of care was significantly lower when compared with usual care.

A WARNING SHOT FOR THE NHS

What patients are telling us just now about their experience of primary care is, I believe, a warning shot across the bows of the NHS. Between 2010 and 2017 in England there was a substantial reduction in overall ratings of patients’ experience of care of about five percentage points — representing something in the order of around 2–2.5 million people in England who in 2010 would have reported favourable experience of care, but who would, in 2017, have less favourable views regarding their care.

Primary care is currently under massive pressure. In our recent survey of 3370 GPs in the South West, 70% of the doctors who responded reported anticipating making career moves within the next 2–5 years, which, if implemented, would ultimately adversely affect patient care; either by quitting patient care, by reducing clinical contact-time, or by taking a career break.¹³ And so there are currently substantial concerns regarding the viability of the GP workforce. GPs continue to provide outstanding quality of care, but there are issues within the system that are working against that ability.

Continuity of care is a major protector to healthcare systems seeking to provide high-quality, affordable care. Recent King’s Fund data identify GPs and their teams as the most trusted element of the NHS.¹⁴ However, GPPS data between 2010 and 2017 identify that, whereas trust in the doctor has been maintained, patient overall experience of care has dropped by 5%, and has fallen substantially by 15%, in respect of continuity of care within that time frame (Figure 1). Freeman has noted that practices generally do not monitor the level of continuity routinely or systematically in the same way that they might monitor and manage access, prescribing rates, or clinical care.¹⁵ This move away from continuity should be a major concern for us all.

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Figure 1.

Changing patient experience of care, 2010–2017, GP Patient Survey data. Based on 1.3 million respondents from c. 8000 practices in England.

Those of you who know me best would be, perhaps, surprised if I did not make reference to what I believe is the best and greatest formulae for living and to the greatest physician, Jesus Christ himself, who set the example for high-quality experience of care in the way he dealt with individuals, and in the washing of his disciples’ feet. The RCGP motto combines science and care. But as the apostle Paul might have written in the Bible: ‘science and care abide, but the greatest of these is care’. Evidencing the delivery of high-quality experience of such care for all our patients remains one of the great challenges for the 21st-century NHS.