Research ArticleOriginal Research

Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007

Stephen M. Campbell, Evangelos Kontopantelis, David Reeves, Jose M. Valderas, Ella Gaehl, Nicola Small and Martin O. Roland
The Annals of Family Medicine November 2010, 8 (6) 499-506; DOI: https://doi.org/10.1370/afm.1145

Article Figures & Data

Tables

  • Table 1.

    Characteristics and Representativeness of Practice Sample (n = 42) Compared With All General Practices in England

    CharacteristicNaMeanSD10th PercentileMedian90th Percentile
    GMS = General Medical Services; IMD = Index of Multiple Deprivation; NHS = National Health Service; QOF = Quality and Outcomes Framework: SOA = Super Output Area.
    a Practice list sizes from GMS data (Reused with the permission of The Health and Social Care Information Centre).
    b QOF achievement obtained from the NHS Information Centre (http://www.qof.ic.nhs.uk/).
    c Data correspond to all practices in England.
    d IMD data available from the Communities and Neighbourhoods Web site (http://webarchive.nationalarchives.gov.uk/+/communities.gov.uk/communities/neighbourhoodrenewal/deprivation/deprivation07/.
    Overall QOFb achievement 2007
        Englandc8,37289.85.084.790.894.1
        Study sample4289.63.586.190.093.1
    Practice list size 2007
        Englandc8,5826,4223,9652,2385,59011,784
        Study sample426,6203,8462,3706,11811,342
    Overall QOF achievement 2005
        Englandc8,50079.88.768.781.788.4
        Study sample4280.67.071.182.288.6
    Practice list size 2005
        Englandc8,4586,2373,8662,1805,40911,553
        Study sample416,6173,8372,4565,92111,481
    Practice list size 2003
        Englandc7,8425,9833,7762,0765,17011,185
        Study sample396,3673,7672,1635,86211,270
    Deprivation: SOA IMDd (2005)
        Englandc8,58226.017.17.421.651.3
        Study sample4227.320.67.320.162.7
  • Table 2.

    Response Rates for Patient Surveys

    Patient Group2003 % (n)2005 % (n)2007 % (n)
    Chronic illness samples55 (1,092)52 (1,040)50 (922)
    Random samples of registered patients47 (3,873)45 (3,601)37 (3,104)
  • Table 3.

    Summary of Practice Mean GPAQ Scale and Individual Item Scores 2003, 2005, and 2007, for Cross-Sectional Samples of Patients With Chronic Illness and Random Samples of Adult Patients

    Samples of Patients With Chronic Illness Mean (SD)aSamples of Randomly Selected Patients Mean (SD)a
    GPAQ Scale and Item200320052007200320052007
    GPAQ = General Practice Assessment Questionnaire.
    Note: See the Appendix for a description of how the scales were scored.
    a Figures relate to raw practice-level scores (mean and standard deviation of practice means).
    Communication scale74.5 (10.1)74.5 (9.3)76.0 (8.5)69.5 (10.0)68.4 (9.4)69.9 (8.9)
    Coordination scale72.1 (7.4)71.0 (5.8)73.0 (5.9)67.0 (5.8)68.6 (5.1)68.3 (6.1)
    Nursing care scale76.0 (6.1)76.1 (6.0)75.3 (8.1)73.9 (6.2)73.4 (5.3)72.9 (7.1)
    Overall satisfaction scale81.6 (8.0)80.6 (8.6)81.3 (7.7)75.2 (9.2)74.7 (10.6)75.6 (7.9)
    Item: In general, how often do you see your usual doctor (continuity of care)?77.2 (8.0)74.9 (9.4)70.4 (9.6)68.2 (13.1)62.8 (13.5)62.5 (11.6)
    Item: Rating of how often patients get to see their usual doctor (rating of continuity of care)71.5 (9.8)69.1 (9.9)67.4 (11.5)64.6 (13.1)61.0 (12.2)61.2 (10.4)
    Item: Do you get an appointment with a particular doctor within 48 hours?36.9 (29.5)38.7 (26.3)37.0 (22.6)33.4 (26.2)35.9 (25.1)32.3 (21.0)
    Item: Rating of how quickly an appointment can be made with a particular doctor in the practice57.3 (17.7)58.0 (14.1)56.6 (15.6)50.0 (18.6)52.2 (16.0)53.0 (13.6)
    Item: Do you get an appointment with any doctor within 48 hours?64.5 (23.9)68.0 (22.6)67.2 (19.9)61.5 (24.2)63.4 (21.0)63.8 (22.4)
    Item: Rating of how quickly an appointment can be made with any doctor in the practice65.2 (15.2)64.5 (13.8)65.5 (14.5)59.2 (17.2)61.2 (14.2)62.4 (13.1)
    Item: If you need an urgent appointment can you get one on the same day?81.8 (17.7)81.2 (15.5)82.2 (16.8)79.6 (17.1)78.2 (17.5)79.4 (18.8)
  • Table 4.

    Results From Regression Analyses of Patients With Chronic Illness and Random Samples in 2003 and 2007

    Mean Change 2003–2007 Chronic Illness SampleMean Change 2003–2007 Random SampleDifference Between Samples Mean Score 2003Difference Between Samples Mean Change 2003–2007
    GPAQ Scale/ItemCoeff (95% CI)Coeff (95% CI)Coeff (95% CI)Coeff (95% CI)
    Coeff=coefficient.
    Note: Results based on postestimation tests of regression coefficients controlling for patient sex, age, ethnicity, accommodation, and employment status. No differences in statistical significance were observed using bootstrap methods.
    Linear regressions
    Communication scale−0.2 (−1.9 to 1)0.4 (−1.3 to 2.1)−2.6 (−4.0 to −1.1)−0.6 (−2.8 to 1.5)
    Coordination scale0.8 (−1.2 to 2.8)−0.1 (−2.2 to 2.0)−2.6 (−4.7 to −0.6)0.9 (−2.0 to 3.8)
    Nursing care scale−0.9 (−2.4 to 0.6)−0.3 (−2.0 to 1.5)−1.1 (−2.7 to 0.5)−0.6 (−2.9 to 1.6)
    Overall satisfaction scale−0.4 (−1.5 to 0.7)0.1 (−1.5 to 1.7)−2.7 (−4.1 to −1.4)−0.5 (−2.4 to 1.4)
    Item: In general, how often do you see your usual doctor (continuity of care)?−6.9 (−8.4 to −4.4)−6.7 (−8.8 to −4.6)−3.5 (−5.3 to −1.7)−0.2 (−2.8 to 2.4)
    Item: Rating of how often patients get to see their usual doctor (rating of continuity of care)−4.8 (−6.2 to −3.4)−4.2 (−6.1 to −2.2)−2.9 (−4.6 to −1.3)−0.6 (−3.0 to 1.8)
    Item: Rating of how quickly an appointment can be made with a particular doctor in the practice2.6 (0.9 to 4.2)−0.8 (−3.2 to 1.6)−3.8 (−5.8 to −1.8)3.4 (0.5 to 6.2)
    Item: Rating of how quickly an appointment can be made with any doctor in the practice3.2 (1.5 to 4.9)0.7 (−1.8 to 3.2)−4.6 (−6.7 to −2.5)2.5 (−0.5 to 5.5)
    Logistic regressionsOR (95% CI)OR (95% CI)OR (95% CI)OR (95% CI)
    Item: Do you get an appointment with a particular doctor within 48 hours?0.98 (0.84 to 1.15)0.97 (0.78 to 1.21)0.90 (0.74 to 1.09)1.01 (0.77 to 1.33)
    Item: Do you get an appointment with any doctor within 48 hours?1.24 (1.06 to 1.45)1.19 (0.94 to 1.50)0.90 (0.74 to 1.09)1.04 (0.79 to 1.38)
    Item: If you need an urgent appointment can you get one on the same day?1.02 (0.83 to 1.27)1.02 (0.76 to 1.38)0.94 (0.73 to 1.22)1.00 (0.69 to 1.44)
  • Appendix.

    Scales and Individual Items for Access and Continuity of Care, of the General Practice Assessment Questionnaire, Used in 2003, 2005, 2007

    Coordination-of-care scale: consisting of 6 items on a 6-point scale from “very poor” to “excellent,” relating to referral within a practice and referral outside a practice separately.
    Communication skills of usual-doctor scale: consisting of 7 items each of which is rated on a 6-point scale ranging from “very poor” to “excellent.”
    Nursing scale: consisting of 3 items using a 6-point scale from “very poor” to “excellent,” relating to patient assessments of the attention nurses give to what patients say, the quality of care provided, and the explanations given about problems/treatments.
    Overall satisfaction scale: consisting of a single 7-point item from “completely satisfied” to “completely dissatisfied.”
    Individual Items Relating to Access and Continuity of Care
    “In general how often do you see your usual doctor?” (6-point scale from ”always” to “never”)
    “How do you rate this [how often you can see your usual doctor]?” (6-point scale, from “very poor” to “excellent”)
    “Thinking of times when you want to see a particular doctor”:
        “How quickly do you get an appointment? ” (6-point scale from “same day” to “more than 5 days”; recoded for analysis as “within 2 days” vs “more than 2 days”)
        “How do you rate this? ” (6-point scale from “very poor” to “excellent”)
    “Thinking of times when you are willing to see any doctor”:
        “How quickly do you get an appointment? ” (6-point scale from “same day” to “more than 5 days”; recoded for analysis as “within 2 days” vs “more than 2 days”)
        “How do you rate this?” (6-point scale from ‘“very poor” to “excellent”)
    “If you need an urgent appointment to see your GP can you normally get one on the same day? ” (“yes” or “no”)

Additional Files

  • The Article in Brief

    Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007

    Stephen M. Campbell , and colleagues

    Background In the United Kingdom, major reforms in primary care policy and practice have been introduced in recent years, including financial incentives to improve clinical quality and provide more rapid access to care. This study set out to examine the impact of these changes on patients' experiences.

    What This Study Found Although there was a modest improvement in access to care for patients with chronic illness, the changes had negative effects on continuity. Patients reported seeing their usual physician less often and gave lower ratings for care continuity and satisfaction. There were no significant changes in quality of care reported by patients before and after the introduction of the government Quality and Outcomes Framework program for communication, nursing care, coordination, and overall satisfaction. For patients with chronic disease, some aspects of urgent access improved significantly (ability to book an urgent appointment and the satisfaction with this experience); however, patients without a long-term condition did not experience this improvement. Patients in both groups reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care in 2007 compared with 2003.

    Implications

    • Efforts to increase access to primary care need to be balanced against the fundamental primary care principle of continuity.
    • Current discussions of the patient-centered medical home in the United States should take into account that initiatives to enhance access to care may compromise continuity.
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