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Understanding high and low patient experience scores in primary care: analysis of patients’ survey data for general practices and individual doctors

BMJ 2014; 349 doi: (Published 11 November 2014) Cite this as: BMJ 2014;349:g6034
  1. Martin J Roberts, research fellow1,
  2. John L Campbell, professor of general practice and primary care1,
  3. Gary A Abel, senior research associate2,
  4. Antoinette F Davey, research fellow1,
  5. Natasha L Elmore, research assistant2,
  6. Inocencio Maramba, associate research fellow1,
  7. Mary Carter, associate research fellow1,
  8. Marc N Elliott, senior principal researcher, chair in statistics3,
  9. Martin O Roland, professor of health services research2,
  10. Jenni A Burt, research associate2
  1. 1University of Exeter Medical School, St Lukes Campus, Exeter EX1 2LU, UK
  2. 2Cambridge Centre for Health Services Research, Institute of Public Health, Forvie Site, University of Cambridge School of Clinical Medicine, Box 113 Cambridge Biomedical Campus, Cambridge CB2 0SR, UK
  3. 3RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA 90407-2138, USA
  1. Correspondence to: J L Campbell john.campbell{at}
  • Accepted 24 September 2014


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.


  • We thank the patients, practice managers, general practitioners, and other staff of the general practices who kindly agreed to participate in this study and without whom the study would not have been possible. Thanks also go to Emily Taylor, Jenny Newbould, Emma Whitton, Amy Gratton, Charlotte Paddison, and Dawn Swancutt for invaluable help with study set-up, practice recruitment, data collection, and data entry. We also thank the Improve Advisory Group for their input and support throughout this study. MJR is now senior psychometrician at the University of Plymouth Peninsula Schools of Medicine and Dentistry, Plymouth, UK.

  • Contributors: MJR wrote the statistical analysis plan, monitored data collection in the south west of England, analysed the data, and drafted and revised the paper. JLC designed the study, wrote the statistical analysis plan, oversaw the conduct of the study, and drafted and revised the paper. GAA contributed to the statistical analysis plan, carried out the sampling of practices, monitored data collection in the east of England/London, and revised the paper. AFD, IM, and MC carried out data collection in the south west, assisted with the data entry and commented on draft versions of the paper. MC and NLE assisted with ethics submissions. NLE carried out data collection in the east of England/London and commented on draft versions of the paper. MNE contributed to the statistical analysis plan and revised the paper. MOR designed the study, oversaw the conduct of the study, and revised the paper. JAB carried out and monitored data collection in the east of England/London, oversaw the conduct of the study, and drafted and revised the paper. JLC is the guarantor.

  • Funding: This work was funded by a National Institute for Health Research Programme Grant for Applied Research (NIHR PGfAR) programme (RP-PG-0608-10050). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: the study was funded by the UK NIHR as an unrestricted research award; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Approval for the study was obtained from the South West 2 Research Ethics Committee on 28 January 2011 (ref: 09/H0202/65). Return of a completed questionnaire was taken to indicate patients’ consent to participate in the study.

  • Declaration of transparency: The lead author (study guarantor) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Data sharing: No additional data available.

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