Search

Competing Interests: Competing interests: GA reports personal fees from Ipsos MORI, outside the submitted work. JB reports she is a member of the Advisory Board for the GP Patient Survey.

Objectives: To examine patient consultation preferences for seeing or speaking to a general practitioner (GP) or nurse; to estimate associations between patient-reported experiences and the type of consultation patients actually received (phone or face-to-face, GP or nurse)., Design: Secondary analysis of data from the 2013 to 2014 General Practice Patient Survey., Setting and Participants: 870 085 patients from 8005 English general practices., Outcomes: Patient ratings of communication and 'trust and confidence' with the clinician they saw., Results: 77.7% of patients reported wanting to see or speak to a GP, while 14.5% reported asking to see or speak to a nurse the last time they tried to make an appointment (weighted percentages). Being unable to see or speak to the practitioner type of the patients' choice was associated with lower ratings of trust and confidence and patient-rated communication. Smaller differences were found if patients wanted a face-to-face consultation and received a phone consultation instead. The greatest difference was for patients who asked to see a GP and instead spoke to a nurse for whom the adjusted mean difference in confidence and trust compared with those who wanted to see a nurse and did see a nurse was -15.8 points (95% CI -17.6 to -14.0) for confidence and trust in the practitioner and -10.5 points (95% CI -11.7 to -9.3) for net communication score, both on a 0-100 scale., Conclusions: Patients' evaluation of their care is worse if they do not receive the type of consultation they expect, especially if they prefer a doctor but are unable to see one. New models of care should consider the potential unintended consequences for patient experience of the widespread introduction of multidisciplinary teams in general practice., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To study the relationships between the different domains of quality of primary health care for the evaluation of health system performance and for informing policy decision making., Data Sources: A total of 137 quality indicators collected from 7,607 English practices between 2011 and 2012., Study Design: Cross-sectional study at the practice level. Indicators were allocated to subdomains of processes of care ("quality assurance," "education and training," "medicine management," "access," "clinical management," and "patient-centered care"), health outcomes ("intermediate outcomes" and "patient-reported health status"), and patient satisfaction. The relationships between the subdomains were hypothesized in a conceptual model and subsequently tested using structural equation modeling., Principal Findings: The model supported two independent paths. In the first path, "access" was associated with "patient-centered care" (β = 0.63), which in turn was strongly associated with "patient satisfaction" (β = 0.88). In the second path, "education and training" was associated with "clinical management" (β = 0.32), which in turn was associated with "intermediate outcomes" (β = 0.69). "Patient-reported health status" was weakly associated with "patient-centered care" (β = -0.05) and "patient satisfaction" (β = 0.09), and not associated with "clinical management" or "intermediate outcomes.", Conclusions: This is the first empirical model to simultaneously provide evidence on the independence of intermediate health care outcomes, patient satisfaction, and health status. The explanatory paths via technical quality clinical management and patient centeredness offer specific opportunities for the development of quality improvement initiatives., (© Health Research and Educational Trust.)

Background: English National Quality Requirements mandate out-of-hours primary care services to routinely audit patient experience, but do not state how it should be done., Objectives: We explored how providers collect patient feedback data and use it to inform service provision. We also explored staff views on the utility of out-of-hours questions from the English General Practice Patient Survey (GPPS)., Methods: A qualitative study was conducted with 31 staff (comprising service managers, general practitioners and administrators) from 11 out-of-hours primary care providers in England, UK. Staff responsible for patient experience audits within their service were sampled and data collected via face-to-face semistructured interviews., Results: Although most providers regularly audited their patients' experiences by using patient surveys, many participants expressed a strong preference for additional qualitative feedback. Staff provided examples of small changes to service delivery resulting from patient feedback, but service-wide changes were not instigated. Perceptions that patients lacked sufficient understanding of the urgent care system in which out-of-hours primary care services operate were common and a barrier to using feedback to enable change. Participants recognised the value of using patient experience feedback to benchmark services, but perceived weaknesses in the out-of-hours items from the GPPS led them to question the validity of using these data for benchmarking in its current form., Conclusions: The lack of clarity around how out-of-hours providers should audit patient experience hinders the utility of the National Quality Requirements. Although surveys were common, patient feedback data had only a limited role in service change. Data derived from the GPPS may be used to benchmark service providers, but refinement of the out-of-hours items is needed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Despite widespread adoption of patient feedback surveys in international health-care systems, including the English NHS, evidence of a demonstrable impact of surveys on service improvement is sparse., Objective: To explore the views of primary care practice staff regarding the utility of patient experience surveys., Design: Qualitative focus groups., Setting and Participants: Staff from 14 English general practices., Results: Whilst participants engaged with feedback from patient experience surveys, they routinely questioned its validity and reliability. Participants identified surveys as having a number of useful functions: for patients, as a potentially therapeutic way of getting their voice heard; for practice staff, as a way of identifying areas of improvement; and for GPs, as a source of evidence for professional development and appraisal. Areas of potential change stimulated by survey feedback included redesigning front-line services, managing patient expectations and managing the performance of GPs. Despite this, practice staff struggled to identify and action changes based on survey feedback alone., Discussion: Whilst surveys may be used to endorse existing high-quality service delivery, their use in informing changes in service delivery is more challenging for practice staff. Drawing on the Utility Index framework, we identified concerns relating to reliability and validity, cost and feasibility acceptability and educational impact, which combine to limit the utility of patient survey feedback., Conclusions: Feedback from patient experience surveys has great potential. However, without a specific and renewed focus on how to translate feedback into action, this potential will remain incompletely realized., (© 2014 The Authors Health Expectations Published by John Wiley & Sons Ltd.)

Background/objectives: To determine which aspects of primary care matter most to patients, we aim to identify those aspects of patient experience that show the strongest relationship with overall satisfaction and examine the extent to which these relationships vary by socio-demographic and health characteristics., Design/setting: Data from the 2009/10 English General Practice Patient Survey including 2,169,718 respondents registered with 8362 primary care practices., Measures/analyses: Linear mixed-effects regression models (fixed effects adjusting for age, gender, ethnicity, deprivation, self-reported health, self-reported mental health condition and random practice effect) predicting overall satisfaction from six items covering four domains of care: access, helpfulness of receptionists, doctor communication and nurse communication. Additional models using interactions tested whether associations between patient experience and satisfaction varied by socio-demographic group., Results: Doctor communication showed the strongest relationship with overall satisfaction (standardized coefficient 0.48, 95% CI = 0.48, 0.48), followed by the helpfulness of reception staff (standardized coefficient 0.22, 95% CI = 0.22, 0.22). Among six measures of patient experience, obtaining appointments in advance showed the weakest relationship with overall satisfaction (standardized coefficient 0.06, 95% CI = 0.05, 0.06). Interactions showed statistically significant but small variation in the importance of drivers across different patient groups., Conclusions: For all patient groups, communication with the doctor is the most important driver of overall satisfaction with primary care in England, along with the helpfulness of receptionists. In contrast, and despite being a policy priority for government, measures of access, including the ability to obtain appointments, were poorly related to overall satisfaction., (© 2013 John Wiley & Sons Ltd.)

Objectives: To describe and explain the primary care experiences of people with multiple long-term conditions in England., Design and Methods: Using questionnaire data from 906,578 responders to the English 2012 General Practice Patient Survey, we describe the primary care experiences of patients with long-term conditions, including 583,143 patients who reported one or more long-term conditions. We employed mixed effect logistic regressions to analyse data on six items covering three care domains (access, continuity and communication) and a single item on overall primary care experience. We controlled for sociodemographic characteristics, and for general practice using a random effect, and further, controlled for, and explored the importance of, health-related quality of life measured using the EuroQoL (EQ-5D) scale., Results: Most patients with long-term conditions report a positive experience of care at their general practice (after adjusting for sociodemographic characteristics and general practice, range 74.0-93.1% reporting positive experience of care across seven questions) with only modest variation by type of condition. For all three domains of patient experience, an increasing number of comorbid conditions is associated with a reducing percentage of patients reporting a positive experience of care. For example, compared with respondents with no long-term condition, the OR for reporting a positive experience is 0.83 (95% CI 0.80 to 0.87) for respondents with four or more long-term conditions. However, this relationship is no longer observed after adjusting for health-related quality of life (OR (95% CI) single condition=1.23 (1.21 to 1.26); four or more conditions=1.31 (1.25 to 1.37)), with pain making the greatest difference among five quality of life variables included in the analysis., Conclusions: Patients with multiple long-term conditions more frequently report worse experiences in primary care. However, patient-centred measures of health-related quality of life, especially pain, are more important than the number of conditions in explaining why patients with multiple long-term conditions report worse experiences of care., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Telephone triage is proposed as a method of managing increasing demand for primary care. Previous studies have involved small samples in limited settings, and focused on nurse roles. Evidence is limited regarding the impact on primary care workload, costs, and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice., Objectives: In comparison with usual care (UC), to assess the impact of GP-led telephone triage (GPT) and nurse-led computer-supported telephone triage (NT) on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice., Design: Pragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation., Setting: General practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk)., Participants: Patients requesting same-day consultations., Interventions: Practices were randomised to GPT, NT or UC. Data collection was not blinded; however, analysis was conducted by a statistician blinded to practice allocation., Main Outcome Measures: Primary - primary care contacts [general practice, out-of-hours primary care, accident and emergency (A&E) and walk-in centre attendances] in the 28 days following the index consultation request. Secondary - resource use and costs, patient safety (deaths and emergency hospital admissions within 7 days of index request, and A&E attendance within 28 days), health status and experience of care., Results: Of 20,990 eligible randomised patients (UC n = 7283; GPT n = 6695; NT n = 7012), primary outcome data were analysed for 16,211 patients (UC n = 5572; GPT n = 5171; NT n = 5468). Compared with UC, GPT and NT increased primary outcome contacts (over 28-day follow-up) by 33% [rate ratio (RR) 1.33, 95% confidence interval (CI) 1.30 to 1.36] and 48% (RR 1.48, 95% CI 1.44 to 1.52), respectively. Compared with GPT, NT was associated with a marginal increase in primary outcome contacts by 4% (RR 1.04, 95% CI 1.01 to 1.08). Triage was associated with a redistribution of primary care contacts. Although GPT, compared with UC, increased the rate of overall GP contacts (face to face and telephone) over the 28 days by 38% (RR 1.38, 95% CI 1.28 to 1.50), GP face-to-face contacts were reduced by 39% (RR 0.61, 95% CI 0.54 to 0.69). NT reduced the rate of overall GP contacts by 16% (RR 0.84, 95% CI 0.78 to 0.91) and GP face-to-face contacts by 20% (RR 0.80, 95% CI 0.71 to 0.90), whereas nurse contacts increased. The increased rate of primary care contacts in triage arms is largely attributable to increased telephone contacts. Estimated overall patient-clinician contact time on the index day increased in triage (GPT = 10.3 minutes; NT = 14.8 minutes; UC = 9.6 minutes), although patterns of clinician use varied between arms. Taking account of both the pattern and duration of primary outcome contacts, overall costs over the 28-day follow-up were similar in all three arms (approximately £75 per patient). Triage appeared safe, and no differences in patient health status were observed. NT was somewhat less acceptable to patients than GPT or UC. The process evaluation identified the complexity associated with introducing triage but found no consistency across practices about what works and what does not work when implementing it., Conclusions: Introducing GPT or NT was associated with a redistribution of primary care workload for patients requesting same-day consultations, and at similar cost to UC. Although triage seemed to be safe, investigation of the circumstances of a larger number of deaths or admissions after triage might be warranted, and monitoring of these events is necessary as triage is implemented., Trial Registration: Current Controlled Trials ISRCTN20687662., Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 13. See the NIHR Journals Library website for further project information.

Objectives: To determine the extent to which practice level scores mask variation in individual performance between doctors within a practice., Design: Analysis of postal survey of patients' experience of face-to-face consultations with individual general practitioners in a stratified quota sample of primary care practices., Setting: Twenty five English general practices, selected to include a range of practice scores on doctor-patient communication items in the English national GP Patient Survey., Participants: 7721 of 15,172 patients (response rate 50.9%) who consulted with 105 general practitioners in 25 practices between October 2011 and June 2013., Main Outcome Measure: Score on doctor-patient communication items from post-consultation surveys of patients for each participating general practitioner. The amount of variance in each of six outcomes that was attributable to the practices, to the doctors, and to the patients and other residual sources of variation was calculated using hierarchical linear models., Results: After control for differences in patients' age, sex, ethnicity, and health status, the proportion of variance in communication scores that was due to differences between doctors (6.4%) was considerably more than that due to practices (1.8%). The findings also suggest that higher performing practices usually contain only higher performing doctors. However, lower performing practices may contain doctors with a wide range of communication scores., Conclusions: Aggregating patients' ratings of doctors' communication skills at practice level can mask considerable variation in the performance of individual doctors, particularly in lower performing practices. Practice level surveys may be better used to "screen" for concerns about performance that require an individual level survey. Higher scoring practices are unlikely to include lower scoring doctors. However, lower scoring practices require further investigation at the level of the individual doctor to distinguish higher and lower scoring general practitioners., (© Roberts et al 2014.)

Background: Young adulthood is an important transitional period during which there is a higher risk of individuals engaging in behaviours which could have a lasting impact on their health. Research has shown that young adults are the lowest responders to surveys about healthcare experiences and are also the least satisfied with the care they receive. However, the factors contributing to this reduced satisfaction are not clear. The focus of our research was to explore the needs and experiences of young adults around healthcare services with an aim of finding out possible reasons for lower satisfaction., Methods: Twenty young adults were interviewed at GP surgeries and at a local young adult advice agency, exploring their experiences and use of primary care services. Interviews were analysed using thematic analysis., Results: The use of primary care services varied amongst the young adult interviewees. Many interviewees reported positive experiences; those who did not linked their negative experiences to difficulties in negotiating their care with the health care system, and reported issues with trust, and communication difficulties. Most of the interviewees were unaware of the use of patient surveys to inform healthcare planning and delivery and were not inclined to take part, mainly because of the length of surveys and lack of interest in the topic area., Conclusions: In order to effectively address the health needs of young adults, young adults need to be educated about their rights as patients, and how to most efficiently use primary care services. GPs should be alert to effective means of approaching and handling the healthcare needs of young adults. A flexible, varied approach is needed to gathering high quality data from this group in order to provide services with information on the changes necessary for making primary care services more accessible for young adults.

Introduction: Multisource feedback (MSF) ratings provided by patients and colleagues are often poorly correlated with doctors' self-assessments. Doctors' reactions to feedback depend on its agreement with their own perceptions, but factors influencing self-other agreement in doctors' MSF ratings have received little attention. We aimed to identify the characteristics of doctors and their rater groups that affect self-other agreement in MSF ratings., Methods: We invited 2454 doctors to obtain patient and colleague feedback using the UK General Medical Council's MSF questionnaires and to self-assess on core items from both patient (PQ) and colleague (CQ) questionnaires. Correlations and differences between doctor, patient and colleague mean feedback scores were examined. Regression analyses identified the characteristics of doctors and their rater groups that influenced self-other score agreement., Results: 1065 (43%) doctors returned at least one questionnaire, of whom 773 (73%) provided self and patient PQ scores and 1026 (96%) provided self and colleague CQ scores. Most doctors rated themselves less favourably than they were rated by either their patients or their colleagues. This tendency to underrate performance in comparison to external feedback was influenced by the doctor's place of training, clinical specialty, ethnicity and the profile of his/her patient and colleague rater samples but, in contrast to studies undertaken in nonmedical settings, was unaffected by age or gender., Discussion: Self-other agreement in MSF ratings is influenced by characteristics of both raters and ratees. Managers, appraisers, and others responsible for interpreting and reviewing feedback results with the doctor need to be aware of these influences., (Copyright © 2013 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.)

Purpose: Clinical quality and patient experience are both widely used to evaluate the quality of health care, but the relationship between these 2 domains remains uncertain. The aim of this study was to examine this relationship using data from 2 established measures of quality in primary care in England., Methods: Practice-level analyses (N = 7,759 practices in England) were conducted on measures of patient experience from the national General Practice Patient Survey (GPPS), and measures of clinical quality from the national pay-for-performance scheme (Quality and Outcomes Framework). Spearman's rank correlation and multiple linear regression were used on practice-level estimates., Results: Although all the correlations between clinical quality summary scores and patient survey scores are positive, and most are statistically significant, the strength of the associations was weak, with the highest correlation coefficient reaching 0.18, and more than one-half were 0.11 or less. Correlations with clinical quality were highest for patient-reported access scores (telephone access 0.16, availability of urgent appointments 0.15, ability to book ahead 0.18, ability to see preferred doctor 0.17) and overall satisfaction (0.15)., Conclusion: Although there are associations between clinical quality and measures of patient experience, the 2 domains of care quality remain predominantly distinct. The strongest correlations are observed between practice clinical quality and practice access, with very low correlations between clinical quality and interpersonal aspects of care. The quality of clinical care and the quality of interpersonal care should be considered separately to give an overall assessment of medical care.

Objectives: Uncertainties exist about when and how best to adjust performance measures for case mix. Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care., Design/setting: Secondary analysis of the 2009 English General Practice Patient Survey. Responses from 2 163 456 patients registered with 8267 primary care practices. Linear mixed effects models were used with practice included as a random effect and five case-mix variables (gender, age, race/ethnicity, deprivation, and self-reported health) as fixed effects., Main Outcome Measures: Primary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services., Results: Depending on the survey measure selected, case-mix adjustment changed the rank of between 0.4% and 29.8% of practices by more than 10 percentile points. Adjusting for case-mix resulted in large increases in score for a small number of practices and small decreases in score for a larger number of practices. Practices with younger patients, more ethnic minority patients and patients living in more socio-economically deprived areas were more likely to gain from case-mix adjustment. Age and race/ethnicity were the most influential adjustors., Conclusions: While its effect is modest for most practices, case-mix adjustment corrects significant underestimation of scores for a small proportion of practices serving vulnerable patients and may reduce the risk that providers would 'cream-skim' by not enrolling patients from vulnerable socio-demographic groups.

Aim: To explore the experiences of people with advanced cancer and/or their caregivers accessing out-of-hours care., Background: The organisation and delivery of out-of-hours in the United Kingdom has undergone major reforms over the past three decades culminating in the new General Medical Service contract in 2004. There are concerns around continuity of care for patients with complex needs under the new arrangements., Design: A qualitative interview study was undertaken recruiting patients from two primary care trusts in Southwest England. Semi-structured interviews were conducted with 28 people with advanced cancer and/or their caregivers who had recently requested out-of-hours care. Interviews were recorded, transcribed and analysed thematically., Findings: Two main themes were identified including the legitimacy of seeking help and continuities of care. Most participants were reluctant to seek help, finding it difficult to decide whether their needs were sufficient to contact services. The degree to which services legitimised participants' requests mediated their experiences. Distress arose when services were dismissive of their needs, whereas respondents were appreciative of clinicians who provided them with reassurance. Participants reported a lack of relational and informational continuity of care. Consulting with an unfamiliar clinician out-of-hours raised doubts in some participants' minds about the quality of care. Some participants recounted episodes in which there were problems with pain management. While the themes suggest that the delivery of out-of-hours care as a whole was not always perfect, around-the-clock access to professional sources of support and reassurance was highly valued. However, the transfer of information to out-of-hours providers remains a key challenge; participants did not understand why out-of-hours providers could not access more information on their medical histories given the level of computerisation within the National Health Service. The findings highlight the need to improve continuity between in-hours and out-of-hours services for patients with complex needs.

Background and Objective: Provision of out-of-hours care in the UK National Health Service (NHS) has changed in recent years with new models of provision and the introduction of national quality requirements. Existing survey instruments tend to focus on users' satisfaction with service provision; most were developed without undertaking supporting qualitative fieldwork. In this study, a survey instrument was developed taking account of these changes in service provision and undertaking supporting qualitative fieldwork. This paper reports on the development and psychometric properties of the new survey instrument, the Out-of-hours Patient Questionnaire (OPQ), which aims to capture information on the entirety of users' experiences of out-of-hours care, from the decision to make contact through to completion of their care management., Methods: An iterative approach was undertaken to develop the new instrument which was then tested in users of out-of-hours services in three geographically distributed UK settings. For the purposes of this study, "service users" were defined as "individuals about whom contact was made with an out-of-hours primary care medical service", whether that contact was made by the user themselves, or via a third party. Analysis was undertaken of the acceptability, reliability and validity of the survey instrument., Results: The OPQ tested is a 56-item questionnaire, which was distributed to 1250 service users. Respondents were similar in respect of gender, but were older and more affluent (using a proxy measure) than non-respondents. Item completion rates were acceptable. Respondents sometimes completed sections of the questionnaire which did not equate to their principal mode of management as recorded in the record of the contact. Preliminary evidence suggests the OPQ is a valid and reliable instrument which contains within it two discrete scales--a consultation satisfaction scale (nine items) and an "entry-access" scale (four items). Further work is required to determine the generalisability of findings obtained following use of the OPQ, especially to non-white user populations., Conclusion: The OPQ is an acceptable instrument for capturing information on users' experiences of out-of-hours care. Preliminary evidence suggests it is both valid and reliable in use. Further work will report on its utility in informing out-of-hours service planning and configuration and standard-setting in relation to UK national quality requirements.

Background: The government has proposed a 48-hour target for GP availability. Although many practices are moving towards delivering that goal, recent national patient surveys have reported a deterioration in patients' reports of doctor availability. What practice factors contribute to patients' perceptions of doctor availability?, Method: A cross sectional patient survey (11,000 patients from 54 inner London practices, 7247 (66%) respondents) using the General Practice Assessment Survey. We asked patients how soon they could be seen in their practice following non-urgent consultation requests and related their aggregated responses to the characteristics of their practice., Results: Three factors relating to practice administration and appointments systems operation independently predicted patients' reports of doctor availability. These were the proportion of patients asked to attend the surgery and wait to be seen, the proportion of patients seen using an emergency surgery arrangement, and the extent of practice computerization., Conclusion: Some practices may have difficulty in meeting the target for GP availability. Meeting the target will involve careful review of practice administrative procedures.

For the management of a condition such as asthma, patients should feel confident with their medication, feel that the treatment is adequate in controlling symptoms and that side-effects of the treatment are minimal. As no comprehensive instrument to measure patient satisfaction with inhaled asthma medication existed, the Satisfaction with Asthma Treatment Questionnaire was developed. The procedures that were used are described, and the initial validation and reliability tests are reported. The study involved focus group meetings, development, testing and modification of a preliminary instrument, and testing of the revised instrument using different samples of patients with asthma. Factor analysis of the 26-item questionnaire identified four domains reflecting four aspects of satisfaction: effectiveness of treatment, ease of use, medication burden, and side-effects and worries. Cronbach's alpha showed evidence of internal consistency reliability. Test/retest reliability ranged from 0.66-0.74. Interscale correlations were moderate-to-high. Significant correlations were found between domain and overall scale scores and patients' overall level of satisfaction. The Satisfaction with Asthma Treatment Questionnaire is potentially a useful instrument for gaining insight into patient satisfaction with inhaled treatment for asthma.

Background: Variations in practice list size are known to be associated with changes in a number of markers of primary care. Few studies have addressed the issue of how single-handed and smaller practices compare with larger group practices and what might be the optimal size of a general practice., Aim: To examine variations in markers of the nature of the care being provided by practices of various size., Design of Study: Practice profile questionnaire survey., Setting: A randomised sample of general practitioners (GPs) and practices from two inner-London areas, stratified according to practice size and patients attending the practice over a two-week period., Method: Average consultation length was calculated over 200 consecutive consultations. A patient survey using the General Practice Assessment Survey instrument was undertaken in each practice. A practice workload survey was carried out over a two-week period. These outcome measures were examined in relation to five measures of practice size based on total list size and the number of doctors providing care., Results: Out of 202 pratices approached, 54 provided analysable datasets. The patient survey response rate was 7247/11,000 (66%). Smaller practices had shorter average consultation lengths and reduced practice performance scores compared with larger practices. The number of patients corrected for the number of doctors providing care was an important predictor of consultation length in group practices. Responders from smaller practices reported improved accessibility of care and receptionist performance, better continuity of care compared with larger practices, and no disadvantage in relation to 10 other dimensions of care. Practices with smaller numbers of patients per doctor had longer average consultation lengths than those with larger numbers of patients per doctor., Conclusion: Defining the optimal size of practice is a complex decision in which the views of doctors, patients, and health service managers may be at variance. Some markers of practice performance are related to the total number of patients cared for, but the practice size corrected for the number of available doctors gives a different perspective on the issue. An oversimplistic approach that fails to account for the views of patients as well as health professionals is likely to be disadvantageous to service planning.

Background: Patients' evaluations are an important means of measuring aspects of primary care quality such as communication and interpersonal care. This study aims to examine variations in assessments of primary care according to age, gender, socioeconomic, and ethnicity variables., Methods: A cross sectional survey of consecutive patients attending 55 inner London practices was performed over a 2 week period using the General Practice Assessment Survey (GPAS) instrument which assesses 13 important dimensions of primary care provision. Variations in scale scores were investigated for differences relating to age, gender, socioeconomic, and ethnic status as reported by respondents., Results: A total of 7692 questionnaires were returned (71% response rate). Valid information on age, gender, socioeconomic status, and ethnicity was available for 4819 out of 5496 adult respondents. Approximately half the respondents reported their ethnic group as "white" and most of the remaining respondents reported belonging to "black" or South Asian groups. Significant differences existed between groups of patients defined by age or ethnicity for most of the scale scores examined. Black, South Asian, and Chinese respondents reported lower scores (representing less favourable assessments) than white respondents; older respondents reported more favourable evaluations of care than younger respondents; and less affluent groups reported lower scores than more affluent groups for two of the 13 dimensions. There was no significant difference between gender groups with respect to assessment of primary care. Age and ethnicity were independent predictors of respondents' assessments of primary care., Conclusions: Differences exist between identifiable subgroups of the population in their assessments of primary health care measured using the GPAS instrument. This work adds to the literature on variation in healthcare experience and the potential for patient assessment of primary care. Further work is required to investigate these differences in more detail and to relate them to differences in the nature and process of primary care provision. Primary care providers need to ensure that services provided are appropriate for all patient groups within their communities.

Objectives: The aim of this study was to describe the psychometric properties of the General Practice Assessment Survey (GPAS) and its acceptability to patients in the UK. GPAS comprises seven multiple item scales and two single item scales addressing nine key areas of primary care activity (access, technical care, communication, inter-personal care, trust, knowledge of patient, nursing care, receptionists and continuity of care). A further four single items relate to patients' perceptions of the GP's role in referral and co-ordination of care, their willingness to recommend their GP and their overall satisfaction with care received., Methods: Two hundred consecutive patients attending routine consulting sessions at 55 inner London practices were invited to complete the GPAS questionnaire. The acceptability, reliability and validity of GPAS was assessed using standard psychometric techniques., Results: Out of 11 000 patients, 7247 (66%) completed a questionnaire in a GP surgery. Fifty-five out of a separate sample of 77 patients attending one practice completed a second questionnaire mailed to them 1 week following their attendance. GPAS was acceptable to patients as evidenced by low proportions of missing data for all items, and a full range of possible scores for all but one of the nine scales. Reliability of the instrument was good. Multiple item scales had excellent internal consistency, high item-total correlations, and test-retest reliability. Scaling assumptions were confirmed, with six of the seven scales achieving 100% scaling success (convergent and discriminant validity). Construct validity was evident, although this requires further evaluation against external measures., Conclusions: GPAS is a useful instrument for assessing several important dimensions of primary care. It is acceptable, reliable and valid, and has the potential for versatility in mode of administration. It will be a useful instrument for practices, primary care groups and primary care researchers evaluating key areas of primary care activity. Further work is required to evaluate its performance in non-inner-city settings and to evaluate further its validity against external criteria.

This study examines the relationship between (i) measures of how appointment systems work; (ii) patients' views of the arrangements for seeing their general practitioner; and (iii) practice self-referral rates to accident and emergency departments (A&E). Nineteen general practices and one district general hospital A&E department in West Lothian, Scotland formed the setting for a prospective study employing analyses of computerized hospital records, of patients surveys, and of data collected by practices during an 8-week study period in 1993. Principal outcome measures were: (i) measures of appointment system operation corrected for practice list size [number of unbooked ('available') appointments, appointment provision, proportion of patients seen as 'extras']; (ii) patient views on practice appointment systems (reported dissatisfaction with arrangements for being seen, proportion of patients reporting they normally wait in excess of 15 minutes when attending to be seen, the perceived availability of a doctor to deal with (a) urgent and (b) non urgent problems); (iii) practice self-referral rates to local A&E department. Practices varied widely in their rate of provision of appointments, in the proportion of appointments which were unbooked at the start of the working day and in the proportion of patients identified as 'extras' by reception staff. These measures of appointment system operation correlated with patient dissatisfaction with the arrangements of seeing a doctor in their practice and with the perceived availability of a doctor to deal with non urgent problems. The measures did not, however, correlate with A&E self-referral rates after they had been corrected for distance between practice and hospital, or with the perceived availability of a doctor to deal with urgent problems.(ABSTRACT TRUNCATED AT 250 WORDS)