Scottish Patient Experience Survey of GP and Local NHS Services 2011/12 Volume 3: Variation in the Experiences of Primary Care Patients

16 Detailed Findings - Other Factors

16.1 The previous sections have considered the effects of patient characteristics on experience. In this section we consider the effects of everything else, mainly related to non-patient characteristics such as: individual GP practice; GP practice size; frequency of appointments; regional level factors; and out-of-hours services.

Effects of individual GP practices

16.2 The survey covered 996 GP practices in Scotland. Even when taking into account all of the other factors discussed in this report, there were still differences in the experiences of people at different practices.

16.3 The greatest variation between practices was for questions related to accessing services (explaining 41 per cent of the variation in the arrangements for getting to see a doctor). There was also considerable variation between practices in the experiences of doctors and nurses, and in the overall care provided. Chart 2 shows the percentage of the variation in experiences explained by the GP practice for selected questions.

Chart 2 Percentage of variation in experience explained by the GP practice for selected questions

16.4 There was little variation between practices in how patients rated the arrangements for getting to see another health professional.

16.5 Looking at the influence of the individual GP practice on experience suggests that patient experience especially around access and staff is strongly influenced by the individual GP practice. This suggests that GP practices can play an important role in looking at ways to improve the experiences of their patients in these areas. Given that we found considerable variation between practices across Scotland, one way of doing this would be to learn from other practices.

16.6 Annex B shows the percentage of variation explained by GP practices for all questions.

GP practice size

16.7 For the analysis we grouped GP practices into five groups by the total number of people registered with them. The number of respondents from each type of practice is shown in Table 14.

Table 14 Number of respondents by GP practice list size

Group - practice list size	Number of respondents	Percentage of respondents
< 2,500	27,388	21
2,500 - 4,999	41,541	31
5,000 - 7,499	34,917	26
7,500 - 9,999	24,724	19
10,000+	16,999	13

16.8 In general, the larger the practice list, the less positive experiences that people had. The difference in experiences was greatest for questions that related to accessing GP services.

16.9 Practice list size had an effect for 28 of the 33 questions that were related to non-out-of-hours GP services. It is worth noting that practice list size only had an effect on 2 out of 6 questions about doctors.

16.10 Part of the reason for people having less positive experiences at larger practices relates to difficulties in being able to make appointments, although it was also a general finding across medium sized (5000+) to large (10,000 +) practices. There was a notable difference in experiences between smaller and larger practices over being able to get through on the phone. Those at smaller practices were much more positive. This finding may be due to smaller practices being better able to manage the volume of calls which will generally be lower.

16.11 Our findings around practice size are consistent with previous studies which show that smaller practices are linked with higher satisfaction around access and continuity of care (Kontopantelis et al 2010, Campbell et al 2001b). Some commentators have suggested that negative experiences around access in larger practices may be more to do with perceived lower levels of continuity of care where patients may be less likely to see the same doctor each time (Fan et al 2005). People in smaller practices may report positive experiences because they are more likely to get to know the practice staff and so it will be easier for them to build good relationships. Larger practices will also experience greater demand for services. Our findings reinforce this assertion as patients were more negative about being able to see their preferred doctor in practices above 5000+ but particularly in the largest practices (10,000+).

Percentage of GP practice list from deprived areas

16.12 In section 8 we discussed the effects on experiences of people living in more deprived areas. We found that those living in the most deprived areas had slightly more positive experiences than those in the least deprived areas. Here we consider the percentage of patients registered on the practice list living in deprived areas and the effect this has on experience. We found that this had an effect for 20 of the 33 questions related to non-out-of-hours services. The effect became stronger for practices serving mainly deprived populations.

16.13 We found that generally people reported less positive experiences as the percentage of people on their practice list living in the most deprived 15% of datazones increased. The effects were greatest when it came to accessing services. A possible explanation is that people from deprived areas may place more demand on services which makes it more difficult for the practice to meet the needs of their patients especially around access.

How often people contacted their GP surgery

16.14 People were asked how often they had contacted their GP practice in the last 12 months. The number of times respondents contacted their GP practice in the last year is shown in Table 15.

Table 15 How often respondents contacted their GP practice in the last year

Group	Number of respondents	Percentage of respondents
Did not contact practice	12,581	9
Once	15,994	12
2-4 times	59,891	45
5-10 times	36,453	27
More than 10 times	16,779	13
Can't remember/don't know	1,704	1
No response or invalid response	2,167	2

16.15 For the analysis we compared groups with the group of people who contacted their practice 2-4 times in the last year, the largest group. Of the 39 questions modelled, the number of contacts with the GP practice had a weak effect on experience for 25 of them. We found that people who had more contact with their GP practice had slightly better experiences.

16.16 This may be explained by those having more contact will have the chance to build good relationships with staff. It may also be that those who have positive experiences are more likely to contact their GP practice.

Effects of Community Health Partnerships (CHPs)

16.17 At the time of the survey there were 36 CHPs in Scotland. There was little variation in the experiences of people in different CHPs once other factors were considered.

16.18 When we published CHP results in May 2012 we found that there was some variation between CHPs. Our new finding shows that this apparent variation between CHPs is actually the result of other factors, including variation between practices within CHPs.

Effects of NHS Boards

16.19 There are 14 territorial NHS Boards in Scotland. There was little variation in the experiences of people in different NHS Boards once other factors were considered.

16.20 When we published NHS Board results in May 2012, we found that there was some variation between Boards. Our new finding shows that this apparent variation between Boards is actually the result of other factors, including variation between practices within Boards.

Effects of different out-of hours services

16.21 People who had used out-of-hours services for themselves or someone they were looking after, in the previous 12 months, were asked which service they spoke to first and who they ended up being treated by. For questions about out-of-hours services we considered the effect on experiences due to the service that the person contacted first and the service that they ended up being treated by.

16.22 The most common journeys through out-of-hours services (Table 16) were:

• 23 per cent of patients first contacted NHS 24⁵ and were then seen by the out-of-hours service
• 13 per cent of patients first contacted NHS 24 and were then treated in A&E/Casualty
• 13 per cent of patients first contacted NHS 24 and received phone advice only
• 11 per cent of patients went to A&E/Casualty and were treated there

Table 16 Percentage of patients treated by each service, by the service they spoke to first

	Service they ended up being treated by:
Service they spoke to first:	Out-of-hours service	A&E/Casualty	Got phone advice only	Ambulance paramedics	Home visit from another doctor/ nurse	Own GP surgery	Pharmacist/Chemist	Emergency Dental Service	Other	Total
NHS 24	23	13	13	6	7	3	1	1	2	69
A&E/Casualty	*	11	*	*	*	*	*	*	*	12
999 Emergency service	*	1	*	3	*	*	*	*	*	5
Pharmacist/ Chemist	1	*	*	*	*	*	3	*	*	4
Out-of-hours service	2	*	*	*	1	*	*	*	*	4
Own GP surgery	*	*	*	*	*	2	*	*	*	3
District nurse/ Community nurse	*	*	*	*	*	*	*	*	*	1
Other	*	*	*	*	*	*	*	*	1	2
Total	27	27	14	10	8	5	4	1	3	100

* Less than 0.5%, but greater than 0%

16.23 We compared services that people spoke to first with the group of people who first spoke to NHS 24 (which was the most common service for people to speak to first). We found that:

• People who first contacted NHS 24 had the least positive experiences.
• People who first contacted the district/community nurse had the most positive experiences.
• People who first contacted the 999 emergency service were more positive about the time they waited and the overall care they received.
• People who first contacted the A&E/casualty; a pharmacist/chemist; their own GP surgery; or another service were slightly more positive. However those contacting A&E/Casualty were slightly less positive about the time they waited.
• People who first contacted the out-of-hours service had similar experiences.

16.24 We compared services that people ended up being treated by with those who received phone advice only. This was not the most common service for people to be treated by but we felt that this made interpretation of the results easier because we compared people against NHS 24 (which is a service delivered by phone) above. We found that:

• People who received phone advice only generally had a less positive experience than other groups.
• People who were treated by ambulance paramedics had the most positive experience.
• People who were treated by the out-of-hours service; their own GP surgery; pharmacist/chemist; emergency dental service; or by a home visit from another doctor or nurse had a more positive experience.
• People who were treated in A&E/Casualty had a slightly more positive experience.
• People who were treated by another service had a less positive experience.

16.25 These results will likely to be influenced by the seriousness of the situations that led people to seek help out-of-hours. The findings that people had less positive experiences of out-of-hours services provided over the phone may be explained by people finding phone consultations with unfamiliar health care professionals more difficult than face-to-face consultations which often involve familiar primary care staff.

16.26 The growth in the use of telephone consultation for healthcare problems has developed partly in response to increased demand for GP and Accident and Emergency (A&E) department care. However evidence about the overall impact and (cost) effectiveness of NHS phone services is limited. In Scotland NHS 24 carries out bi-annual surveys to establish how satisfied patients are with the service provided. A total of 91% of respondents to a 2011 survey reported overall satisfaction with the service (NHS 24 2011).