Jennifer Anne Burt

Experiences of care planning in England: interviews with patients with long term conditions

BackgroundThe prevalence and impact of long term conditions continues to rise. Care planning for people with long term conditions has been a policy priority in England for chronic disease management. However, it is not clear how care planning is currently understood, translated and implemented in primary care. This study explores experience of care planning in patients with long term conditions in three areas in England.MethodsWe conducted semi-structured interviews with 23 predominantly elderly patients with multiple long term conditions. The interviews were designed to explore variations in and emergent experiences of care planning. Qualitative analysis of interview transcripts involved reflexively coding and re-coding data into categories and themes.ResultsNo participants reported experiencing explicit care planning discussions or receiving written documentation setting out a negotiated care plan and they were unfamiliar with the term ‘care planning’. However, most described some components of care planning which occurred over a number of contacts with health care professionals which we term”reactive” care planning. Here, key elements of care planning including goal setting and action planning were rare. Additionally, poor continuity and coordination of care, lack of time in consultations, and patient concerns about what was legitimate to discuss with the doctor were described.ConclusionsAmongst this population, elements of care planning were present in their accounts, but a structured, comprehensive process and consequent written record (as outlined in English Department of Health policy) was not evident. Further research needs to explore the advantages and disadvantages of different approaches to care planning for different patient groups.

The role of patient experience surveys in quality assurance and improvement: a focus group study in English general practice

Despite widespread adoption of patient feedback surveys in international health‐care systems, including the English NHS, evidence of a demonstrable impact of surveys on service improvement is sparse.

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

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 15u2009172 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.

Variations in GP–patient communication by ethnicity, age, and gender: evidence from a national primary care patient survey

Background Doctor–patient communication is a key driver of overall satisfaction with primary care. Patients from minority ethnic backgrounds consistently report more negative experiences of doctor–patient communication. However, it is currently unknown whether these ethnic differences are concentrated in one gender or in particular age groups. Aim To determine how reported GP–patient communication varies between patients from different ethnic groups, stratified by age and gender. Design and setting Analysis of data from the English GP Patient Survey from 2012–2013 and 2013–2014, including 1 599 801 responders. Method A composite score was created for doctor–patient communication from five survey items concerned with interpersonal aspects of care. Mixed-effect linear regression models were used to estimate age- and gender-specific differences between white British patients and patients of the same age and gender from each other ethnic group. Results There was strong evidence (P<0.001 for age by gender by ethnicity three-way interaction term) that the effect of ethnicity on reported GP–patient communication varied by both age and gender. The difference in scores between white British and other responders on doctor–patient communication items was largest for older, female Pakistani and Bangladeshi responders, and for younger responders who described their ethnicity as ‘Any other white’. Conclusion The identification of groups with particularly marked differences in experience of GP–patient communication — older, female, Asian patients and younger ‘Any other white’ patients — underlines the need for a renewed focus on quality of care for these groups.

Investigating the relationship between consultation length and patient experience: a cross-sectional study in primary care

Background Longer consultations in primary care have been linked with better quality of care and improved health-related outcomes. However, there is little evidence of any potential association between consultation length and patient experience. Aim To examine the relationship between consultation length and patient-reported communication, trust and confidence in the doctor, and overall satisfaction. Design and setting Analysis of 440 videorecorded consultations and associated patient experience questionnaires from 13 primary care practices in England. Method Patients attending a face-to-face consultation with participating GPs consented to having their consultations videoed and completed a questionnaire. Consultation length was calculated from the videorecording. Linear regression (adjusting for patient and doctor demographics) was used to investigate associations between patient experience (overall communication, trust and confidence, and overall satisfaction) and consultation length. Results There was no evidence that consultation length was associated with any of the three measures of patient experience (P >0.3 for all). Adjusted changes on a 0–100 scale per additional minute of consultation were: communication score 0.02 (95% confidence interval [CI] = −0.20 to 0.25), trust and confidence in the doctor 0.07 (95% CI = −0.27 to 0.41), and satisfaction −0.14 (95% CI = −0.46 to 0.18). Conclusion The authors found no association between patient experience measures of communication and consultation length, and patients may sometimes report good experiences from very short consultations. However, longer consultations may be required to achieve clinical effectiveness and patient safety: aspects also important for achieving high quality of care. Future research should continue to study the benefits of longer consultations, particularly for patients with complex multiple conditions.

Wasting the doctor's time? A video-elicitation interview study with patients in primary care

Reaching a decision about whether and when to visit the doctor can be a difficult process for the patient. An early visit may cause the doctor to wonder why the patient chose to consult when the disease was self-limiting and symptoms would have settled without medical input. A late visit may cause the doctor to express dismay that the patient waited so long before consulting. In the UK primary care context of constrained resources and government calls for cautious healthcare spending, there is all the more pressure on both doctor and patient to meet only when necessary. A tendency on the part of health professionals to judge patients decisions to consult as appropriate or not is already described. What is less well explored is the patients experience of such judgment. Drawing on data from 52 video-elicitation interviews conducted in the English primary care setting, the present paper examines how patients seek to legitimise their decision to consult, and their struggles in doing so. The concern over wasting the doctors time is expressed repeatedly through patients narratives. Referring to the sociological literature, the history of ‘trivia’ in defining the role of general practice is discussed, and current public discourses seeking to assist the patient in developing appropriate consulting behaviour are considered and problematised. Whilst the patient is expected to have sufficient insight to inform timely consulting behaviour, it becomes clear that any attempt on the part of doctor or patient to define legitimate help-seeking is in fact elusive. Despite this, a significant moral dimension to what is deemed appropriate consulting by doctors and patients remains. The notion of candidacy is suggested as a suitable framework and way forward for encompassing these struggles to negotiate eligibility for medical time.

Patients’ use and views of real-time feedback technology in general practice

There is growing interest in real‐time feedback (RTF), which involves collecting and summarizing information about patient experience at the point of care with the aim of informing service improvement.

Doctors’ engagements with patient experience surveys in primary and secondary care: a qualitative study

Patient experience surveys are increasingly important in the measurement of, and attempts to improve, health‐care quality. To date, little research has focused upon doctors’ attitudes to surveys which give them personalized feedback.

Language spoken at home and the association between ethnicity and doctor–patient communication in primary care: analysis of survey data for South Asian and White British patients

Objectives To investigate if language spoken at home mediates the relationship between ethnicity and doctor–patient communication for South Asian and White British patients. Methods We conducted secondary analysis of patient experience survey data collected from 5870 patients across 25 English general practices. Mixed effect linear regression estimated the difference in composite general practitioner–patient communication scores between White British and South Asian patients, controlling for practice, patient demographics and patient language. Results There was strong evidence of an association between doctor–patient communication scores and ethnicity. South Asian patients reported scores averaging 3.0 percentage points lower (scale of 0–100) than White British patients (95% CI −4.9 to −1.1, p=0.002). This difference reduced to 1.4 points (95% CI −3.1 to 0.4) after accounting for speaking a non-English language at home; respondents who spoke a non-English language at home reported lower scores than English-speakers (adjusted difference 3.3 points, 95% CI −6.4 to −0.2). Conclusions South Asian patients rate communication lower than White British patients within the same practices and with similar demographics. Our analysis further shows that this disparity is largely mediated by language.

Rating Communication in GP Consultations: The Association Between Ratings Made by Patients and Trained Clinical Raters

Patient evaluations of physician communication are widely used, but we know little about how these relate to professionally agreed norms of communication quality. We report an investigation into the association between patient assessments of communication quality and an observer-rated measure of communication competence. Consent was obtained to video record consultations with Family Practitioners in England, following which patients rated the physician’s communication skills. A sample of consultation videos was subsequently evaluated by trained clinical raters using an instrument derived from the Calgary-Cambridge guide to the medical interview. Consultations scored highly for communication by clinical raters were also scored highly by patients. However, when clinical raters judged communication to be of lower quality, patient scores ranged from “poor” to “very good.” Some patients may be inhibited from rating poor communication negatively. Patient evaluations can be useful for measuring relative performance of physicians’ communication skills, but absolute scores should be interpreted with caution.