Primary care

Setting standards based on patients' views on access and continuity: secondary analysis of data from the general practice assessment survey

Peter Bower, senior research fellow ^a, Martin Roland, director ^a, John Campbell, professor ^b, Nicola Mead, research fellow ^a. 

^a National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL, ^b Department of General Practice and Primary Care, Peninsula Medical School, Exeter EX2 5DW

Correspondence to: P Bower peter.bower{at}man.ac.uk

	Abstract

Top Abstract Introduction Methods Results Discussion References

Objectives: To examine patients' views on access and continuity in general practice to derive quality standards.
Design: Secondary analysis of data from general practice research studies and routine quality assessment activities undertaken by practices and primary care trusts.
Setting: General practice.
Participants: General practice patients.
Results: Satisfactory standards of access were next day appointments with general practitioners and a 6-10 minute wait for consultations to begin. A satisfactory level of continuity was seeing the same general practitioner "a lot of the time." Standards varied with the analytic method used and by sociodemographic group.
Conclusions: Standards expected by patients in primary care can be derived from linked report-assessment pairs. Patients may have expectations of access that are in excess of government targets. Patients also have high expectations of continuity of care. It is unclear the degree to which such standards are reliable or valid, how conflicts between access and continuity should be resolved, or how these standards relate to other priorities of patients such as high quality interpersonal care.

What is already known on this topic Standards are increasingly being set for the provision of health services Surveys and consultation exercises before the NHS plan helped set the standard for a maximum waiting time of 48 hours for appointments to see general practitioners The optimal methods by which patients should be involved in setting standards and the utility of such standards are unclear What this study adds Satisfactory standards of access were next day appointments, a 6-10 minute wait for consultations to begin, and seeing the same general practitioner a lot of the time Patients may have expectations for access to primary care in excess of current government targets

	Introduction

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The UK government has emphasised the measurement of performance in the NHS, including the setting of standards, some of which legitimately include the views of patients. ^{1 2} For example, patient surveys and consultation exercises before the NHS plan helped set the standard for a maximum waiting time of 48 hours for appointments to see general practitioners. ^{3 4}

Another approach to setting standards is provided by the general practice assessment survey, a self report questionnaire examining patients' views of aspects of general practice.⁵ Some scales in the questionnaire use two types of items: report (the patient's experience of care) and assessment (the patient's evaluation of that experience). These report-assessment pairs relate to waiting times for appointments with a particular general practitioner, with any general practitioner, and for consultations to begin, and the proportion of consultations with the patient's usual general practitioner (continuity of care).

We aimed to examine relations between reports of access and continuity in general practice and assessments of acceptability to derive patient based standards and to examine differences in standards between patients from different sociodemographic groups.

	Methods

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The general practice assessment survey comprises multiple subscales, but we restricted our analysis to access and continuity items with report-assessment pairs.⁶ The relevant items are listed on bmj.com (a copy of the questionnaire is available at www.gpas.co.uk). The survey is completed by patients attending surgeries or sent by post to those on the practice list. However, items refer to care in general, not to specific consultations.

The data (21 905 patients) derive from a survey of quality of care, a questionnaire validation study, an evaluation of pilots for personal medical services, and data analysed for primary care groups and trusts by the National Primary Care Research and Development Centre. ^{5 7 8} Table 1 details the source of the data.

Statistical methods
We used cross tabulation to examine patterns of missing data and for the main analysis of relations between reports and assessments. For simplicity, we dichotomised assessments of satisfaction into dissatisfied (very poor, poor, or fair) and satisfied (good, very good, excellent).

To set standards, a minimum proportion of patients (for example, three quarters) might be prescribed who must be satisfied with a given aspect of the service. Such criteria are unambiguous but also arbitrary and are sensitive to relatively small differences in the proportion of satisfied patients (for example, between 74% and 76%). Alternatively, standards might be based on large discontinuities in the data. For example, if a large proportion of patients are satisfied at one level of service (with an appointment the next day, for example) and far fewer are satisfied with the next level (waiting two or three days), then this might suggest a degree of agreement among patients as to an acceptable level of service. Such an approach is less arbitrary and more sensitive to the actual distribution of data.

We used both methods in our analyses. The first criterion was that three quarters of patients should report being satisfied, which we then relaxed to two thirds of patients. In addition, a large discontinuity was defined as an absolute percentage change of greater than 25% in the proportion of satisfied patients between different levels of service. Where there was more than one such discontinuity, we took the largest.

To examine effects of demographic characteristics, we stratified raw cross tabulations by age (16-30, 31-45, 46-59, 60), sex, ethnicity (white or other), chronic illness (yes or no), employment (employed full or part time or other), and accommodation (owner occupied or other).

	Results

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Table 2 shows the raw cross tabulations of report and assessment items. We found at least one identifiable discontinuity in all analyses and more than one discontinuity in some. Table 3 shows the standards identified by the different methods.

Associations with sociodemographic variables produced relatively minor variations in the identified standards. Acceptable waiting time for consultations to begin was the issue most sensitive to sociodemographic factors. Age and ethnicity were the most consistent moderating factors, with patients from ethnic minorities generally having higher standards and patients in the older two age groups (46-59, 60 years) having lower standards. Details of these minor variations are shown on bmj.com.

	Discussion

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Standards for primary care services can be derived from linked report-assessment pairs in the general practice assessment survey. Our methods suggest that patients may have expectations of access that are in excess of government targets and also have high expectations of continuity of care. Two key issues are raised. The first is the methodological adequacy of this approach to standard setting. The second, dependent on the first, concerns policy implications of the analysis.

Our analysis was suggested by the nature of the items in the general practice assessment survey, but the questionnaire was not designed explicitly as an instrument for setting standards. The processes by which patients make judgments in situations designed to elicit standards may differ from those used in completion of routine questionnaires.

The results depend on the validity and reliability of the questionnaire. The questionnaire is reliable and has an interpretable factor structure. ^{5 9} However, patient reports of waiting times have not been validated against objective measures, and validation of subjective assessments of acceptability is problematic.

The standards identified obviously depend on the particular definition of satisfaction and the thresholds applied (66%, 75%, or discontinuities). The binary definition of satisfaction is similar to published recommendations, but ratings of fair might be considered indicative of some degree of satisfaction. ^{10 11} If the data are reanalysed in such a way, different results occur (for example, both 66% and 75% of patients are satisfied with waiting two or three days for an appointment with a specific general practitioner, waiting 11-20 minutes for consultations to begin, and seeing the same general practitioner "some of the time"). In the identification of standards, the 66% and 75% criteria are obviously arbitrary. The presence of discontinuities in the data suggests that thresholds of acceptability do exist, but it should be noted that this method was suggested by preliminary analysis, and a discontinuity was not defined a priori.

The validity of the standards also depends on the representativeness of the sample. The data derive from several sources including practices using the general practice assessment survey for routine service evaluation, although 69% of the present sample derives from three research studies. ^{5 7 8} One of these studies had a response rate of only 38%, whereas another achieved a rate of 66%. ^{5 7} However, when our analysis was restricted to data from the study with the higher response rate, the results remained unchanged.

The methods of standard setting used by us did not prove highly sensitive to sociodemographic factors (although the dichotomising of sociodemographic variables such as ethnicity may have concealed important variations). Finally, the high standards relating to access and continuity derived from our analysis may reflect that they have not been explicitly compared with other aspects of primary care for their overall priority.¹² Quality of care in primary care is a combination of access to care and effectiveness of the care provided, and surveys of primary care patients in Europe suggest that interpersonal aspects may be more important than access issues such as waiting times for consultations (ranked 34th of 38 aspects of primary care in the United Kingdom). ^{13 14} It should be noted, however, that a quick service for emergencies was ranked first in the same survey (our study did not include a measure of perceived urgency), and rapid access to appointments has also been ranked highly in previous studies. ^{14 15}

Conclusion
Report-assessment pairs in the general practice assessment survey provide a method for examining patients' views of general practice that may be of use in setting standards and monitoring performance. Patients have high expectations relating to access to care, which may support or exceed current government targets, including the standard for waiting times by 2004 of seeing a general practitioner within 48 hours.⁴ The interpretation of standards must be sensitive to the methods used to derive them, however, and to issues of priority in other aspects of general practice, such as the effectiveness of interpersonal care. Although access to services is an important issue in itself, some definitions of access include notions of effectiveness, and thus evidence concerning the clinical and cost benefits of rapid access is also of importance in the wider debate.¹⁶

	Acknowledgments

We thank Sophie Jerrim for assistance with the database of questionnaires and all those who provided data.

Contributors: See bmj.com

	Footnotes

Funding: This work was conducted as part of the programme of the National Primary Care Research and Development Centre, supported by the Department of Health. The views expressed are those of the authors and are not intended to represent the views of National Primary Care Research and Development Centre or its funders.

Competing interests: None declared.

This is an abridged version; the full version is on bmj.com

Additional tables appear on bmj.com

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(Accepted 25 November 2002)