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Patients’ experience and satisfaction in primary care: secondary analysis using multilevel modelling

BMJ 2010; 341 doi: (Published 12 October 2010) Cite this as: BMJ 2010;341:c5004
  1. Chris Salisbury, professor of primary health care1,
  2. Marc Wallace, ST2 core medical doctor2,
  3. Alan A Montgomery, reader in health services research1
  1. 1University of Bristol, Bristol BS8 2AA, UK
  2. 2Royal Berkshire Hospital, Reading RG1 5AN, UK
  1. Correspondence to: C Salisbury c.salisbury{at}
  • Accepted 26 July 2010


Objective To explore whether responses to questions in surveys of patients that purport to assess the performance of general practices or doctors reflect differences between practices, doctors, or the patients themselves.

Design Secondary analysis of data from a study of access to general practice, combining data from a survey of patients with information about practice organisation and doctors consulted, and using multilevel modelling at practice, doctor, and patient level.

Setting Nine primary care trusts in England.

Participants 4573 patients who consulted 150 different doctors in 27 practices.

Main outcome measures Overall satisfaction; experience of wait for an appointment; reported access to care; satisfaction with communication skills.

Results The experience based measure of wait for an appointment was more discriminating between practices (practice level accounted for 20.2% (95% confidence interval 9.1% to 31.3%) of variance) than was the overall satisfaction measure (practice level accounted for 4.6% (1.6% to 7.6%) of variance). Only 6.3% (3.8% to 8.9%) of the variance in the doctors’ communication skills measure was due to differences between doctors; 92.4% (88.5% to 96.4%) of the variance occurred at the level of the patient (including differences between patients’ perceptions and random variation). At least 79% of the variance on all measures occurred at the level of the patient, and patients’ age, sex, ethnicity, and housing and employment status explained some of this variation. However, adjustment for patients’ characteristics made very little difference to practices’ scores or the ranking of individual practices.

Conclusions Analyses of surveys of patients should take account of the hierarchical nature of the data by using multilevel models. Measures related to patients’ experience discriminate more effectively between practices than do measures of general satisfaction. Surveys of patients’ satisfaction fail to distinguish effectively between individual doctors because most of the variation in doctors’ reported performance is due to differences between patients and random error rather than differences between doctors. Although patients’ reports of satisfaction and experience are systematically related to patients’ characteristics such as age and sex, the effect of adjusting practices’ scores for the characteristics of their patients is small.


  • We thank the patients and practices that participated and the Advanced Access Evaluation Team that did the research on which this analysis is based.

  • Contributors: CS led the evaluation of advanced access, with methodological support from AAM. CS had the idea for this paper. CS and MW did the analysis, with advice from AAM. CS wrote the paper, with comments from MW and AAM. All authors revised and approved the final paper. CS is the guarantor.

  • Funding: The evaluation of advanced access was funded by the NHS Research and Development Programme on Service and Delivery Organisation (ref SDO/70/2004). The views expressed in this publication are those of the authors and not necessarily those of the funders. This secondary analysis had no specific funding. The funders had no input into study design; the collection, analysis, or interpretation of data; the writing of the report; or the decision to submit the article for publication. The authors are independent from the research funders.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that CS, MW, and AM, and their spouses, partners, and children, have no financial or non-financial interests that may be relevant to the submitted work.

  • Ethical approval: Thames Valley Multicentre Research Ethics Committee approved this study (ref 04/12/024).

  • Data sharing: No additional data available.

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