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Understanding why some ethnic minority patients evaluate medical care more negatively than white patients: a cross sectional analysis of a routine patient survey in English general practices

BMJ 2009; 339 doi: (Published 17 September 2009) Cite this as: BMJ 2009;339:b3450
  1. Nicola Mead, research fellow1,
  2. Martin Roland, professor of health services research2
  1. 1NIHR School for Primary Care, University of Manchester, Manchester M13 9PL
  2. 2General Practice and Primary Care Research Unit, University of Cambridge, Cambridge CB2 0SR
  1. Correspondence to: Martin Roland martin.roland{at}
  • Accepted 17 August 2009


Objective To examine why patients from ethnic minorities give poorer evaluations of primary health care than white patients.

Design Cross sectional analysis of patient surveys collected in general practice.

Setting 1098 English general practices that undertook a routine survey of patients using the General Practice Assessment Questionnaire between April 2005 and March 2006.

Participants 188 572 survey respondents, 95.8% of whom identified themselves as “white,” “black/black British,” “Asian/Asian British,” or “Chinese.” Analyses were restricted to between 133 441 (71%) and 147 686 (78%) respondents with complete data on relevant variables.

Main outcome measures Patient evaluations of waiting times for general practitioner appointments, time spent waiting in surgeries for consultations to start, and continuity of care.

Results All aspects of care were rated substantially lower by respondents from the three ethnic minority groups than by white patients. Poorer evaluations of time spent waiting for consultations to begin (rated lowest by Asian patients) and continuity of care (rated lowest by Chinese patients) appeared to reflect worse reported experiences by ethnic minority groups. Substantial differences between white and ethnic minority patients’ ratings of appointment waiting times persisted, however, even after adjusting for the actual time patients reported waiting. This effect disappeared for Chinese and black respondents after adjusting for evaluations of reception staff and doctors’ communication skills, but Asian patients’ ratings remained considerably lower than those of white respondents.

Conclusions Important differences in assessments of care exist in different ethnic minority groups. Some negative evaluations may reflect communication issues. Among Asian patients, lower ratings of waiting times for appointments may also reflect different expectations of care. Adjusting survey results for ethnicity may be justified when comparing healthcare providers; however, health services also have a responsibility to meet legitimate patient expectations.


  • The authors thank Mark Hann and Pete Bower for advice on the statistical analyses and comments on earlier drafts, and the reviewers for their helpful comments concerning interpretation of the data.

  • Contributors: Both authors developed the research questions and planned the analyses. NM conducted the analyses, and both authors were responsible for writing the paper. NM had full access to all the data and takes responsibility for the integrity of the data and the accuracy of the analyses. NM is the guarantor.

  • Funding: This article presents independent research conducted by the National Primary Care Research and Development Centre and supported by core funding from the Department of Health. NM is funded by the National Institute for Health Research. The views expressed in this publication are those of the authors and not those of the NHS, the National Institute for Health Research, or the Department of Health.

  • Competing interests: The GPAQ is free to use for NHS staff, but commercial companies selling patient evaluation services were required to pay a licence fee at the time these data were collected. Funds derived from selling the GPAQ in these instances were received by the National Primary Care Research and Development Centre and used to fund support for the GPAQ and related research. No individual gains directly from use of the GPAQ.

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