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EXECUTIVE SUMMARY
1. INTRODUCTION
In 2000 a survey was conducted on behalf of the Scottish Executive Health Department (SEHD) to examine public attitudes to the NHS in Scotland, and to inform development of 'Our National Health - A Plan for Action, A Plan for Change', essentially setting out the modernising agenda for the NHS in Scotland. Since the publication of 'Our National Health' a number of important changes have been made to the provision of NHS services, and in order to inform further policy development and identify areas in which more work might be needed, the SEHD commissioned NOP Social and Political to undertake a new survey in the spring of 2004. (See Chapter 1)
2. RESEARCH METHODOLOGY AND ANALYSIS
The design of this survey was similar to that used in 2000 and involved 2600 telephone interviews conducted with a representative quota sample of adults aged 16 and over from all parts of Scotland. Fieldwork was carried out in March and April 2004. Data was weighted by key demographic variables to ensure that the sample was representative. The data was used in bi-variate and multi-variate statistical analysis. (See Chapter 2)
Where relevant, comparisons have been drawn with the 2000 survey but these are somewhat limited because of changes in question wording. The 2004 research is intended to establish a new baseline in the context of modernisation of the NHS in Scotland and further surveys in 2006 and 2008 will allow assessment of change over time. (See Chapter 2)
3. DEMOGRAPHIC PROFILE, GENERAL HEALTH AND LONG-STANDING CONDITIONS
The sample was representative in terms of sex, age and tenure when compared to the 2001 Census. The data was weighted for social class and the urban/rural split was close to that recorded in the Executive's Scottish Household Survey. Of all the demographic factors used in the data analysis, sex and age were often the most powerful in explaining attitudes. (See 3.1-3.16)
Seven out of ten (70%) people in the sample rated their own general health as very good or excellent. The best health was enjoyed by those people from AB (professional and managerial) households and those aged under 25. (See 3.17)
A third of respondents (35%) had a long-standing disability, illness or infirmity and a quarter of the sample (24%) were limited by this condition. (See 3.19-3.20)
4. AWARENESS AND USE OF SERVICES
The sample was questioned about awareness of a range of eleven NHS services and initiatives - some of these were relatively new or, in the case of NHS 24, were not nationally available at the time of the survey. These new services are part of a shift in emphasis to improve responsiveness and accessibility in the NHS in Scotland. (See 4.1)
The levels of awareness of services varied from 69% for day-case admissions down to 27% for patients having a choice of where to go to see a health professional. More than half of the sample were aware of other health professionals trained to deal with a range of health issues, consultations with pharmacists, NHS 24, Out-of-hours services and increased treatment as an outpatient rather than having an inpatient admission. Awareness of patient choice initiatives such as having a choice of where a professional can be seen, the ability to a see a specialist at a local surgery and having a choice of appointment times was low. Women and those in ABC1 households were most likely to be aware of almost all of these initiatives or services. (See 4.2-4.13)
Across the range of NHS services, women of all ages, along with men aged over 55, were most likely to be multiple users, i.e. they used a wider range of services than other people. (See 4.14-4.18)
One in five of those aware of NHS 24 had called the service in the last year - there may be some more potential to reduce the demands placed on other, more resource-intensive services, once NHS 24 is rolled out across Scotland. Just over 40% of people who knew about pharmacist consultations had used this service in the previous 12 months. One in six respondents who had heard about getting prescriptions from someone other than a doctor said that they had used this service in the past year. (See 4.19-4.21)
Three-quarters of the overall sample had used at least one of the six main NHS services in the last year - Out-of-hours (12%), telephone consultations (14%), the Primary Health Care Team at a surgery (65%), home visits (9%), outpatient services (34%) or inpatient admissions (17%). (See 4.22-4.24)
Women aged under 55 were most likely to have used the Out-of-hours service. The majority of users saw a GP in person at a clinic (though rarely their own doctor) while a quarter of cases involved a home visit. (See 4.25-4.27)
As with Out-of-hours services, women aged 16-54 were most likely to have had telephone consultations with someone from the local surgery (during normal hours). This contact was mainly with the respondent's own GP though a fifth of users had spoken to a nurse. (See 4.28-4.29)
Women aged 16-54 were also more likely than men of the same age to have been to their local surgery in the last year. Only half the sample of men aged 16-34 had attended their local surgery in the last year. Usage for men and women 'peaked' by the age of 65, although the lower attending rate for older people may be partly explained by their greater likelihood of having home visits from surgery staff. While nearly nine in ten visitors to the surgery had seen their own GP in the last year, more than half of them, notably older respondents, had (also) seen the Practice Nurse. The evidence from the survey suggests that the policy of changing professional boundaries is resulting in more contact with nurses in Primary Care. (See 4.30-4.32)
Use of home visits correlates closely with age - nearly a quarter of those aged over 75 had made use of this NHS service in the previous 12 months. Most of this contact was with GPs but around a third involved nurses or health visitors. (See 4.33-4.35)
There were no sex differences in terms of outpatient appointments but the over-65s (43%) were much more likely to have used this service than the under-45s (27%). (See 4.36)
Inpatient admissions were most common among those from DE households (i.e. homes headed by unskilled manual workers or those reliant on state benefits) and people renting from social landlords. Age was not such a strong indicator of inpatient admissions. A third of admissions were day cases, notably for younger users. (See 4.37-4.39)
5. SATISFACTION WITH SERVICES
The levels of satisfaction were high for the contact with all of the main service areas examined in this survey. However, overall satisfaction with use of NHS services was lower - respondents tended to be 'fairly satisfied' rather than 'very satisfied'. Relatively low satisfaction was recorded for the under-35s in respect of two service areas - Practice Nurses and outpatient services - otherwise there were few demographic differences. (See 5.2-5.24)
About 90% of users were very or fairly satisfied with each of the eight services covered in the survey. Primary Care analysis was broken down into own and other GPs and Practice Nurses seen at the local surgery. The highest combined score was 93% for contact with the Practice Nurse and the lowest was 86% for outpatient services. No more than 10% of users were actually dissatisfied with any one service. The proportions of users who were very satisfied was lower for Out-of-hours and outpatient services than for any of the other service areas. (See 5.2-5.24)
There was evidence of a link between satisfaction with a service and the wait to access this contact with the NHS - this was apparent for waits of over 48 hours to see someone at the surgery and for longer waits after referral for an outpatient appointment. (See 5.6 and 5.15)
A large majority of users of both outpatient (84%) and elective inpatient (93%) services said that the experience had been well co-ordinated. However, this positive headline figure still means that 15% of outpatients were unhappy with this aspect of the service provided by the NHS. (See 5.16 and 5.20)
As noted above, overall satisfaction with NHS services used in the last year was lower than the scores recorded for the individual service areas - notably fewer people were 'very satisfied' in overall terms. For example, 37% were very satisfied with their overall use of the health service compared with the 53% who held this view about outpatient services (the lowest score for an individual service). Factors such as press coverage and word of mouth may influence views and other research evidence shows that this divergence of views is happening in other public services across the UK. Younger respondents were the least satisfied overall, though even here only 8% of respondents were actually dissatisfied with their use of the NHS in Scotland. (See 5.21-5.24)
Rather more people (27%) thought that the NHS had got worse over the last few years than felt the health service had improved (20%) - however, nearly half of the sample thought that there had been no change. Women aged 35-54 were generally more negative than men with regards to feeling that the NHS had got worse rather than better. (See 5.25)
In contrast, there was a net positive balance with regard to the future - 39% expected improvements while 23% thought that the situation would worsen. Again, many people anticipated no change. The youngest and oldest respondents were the most optimistic with women aged 35-54 and those in small rural towns being the most pessimistic. These attitudes to the future of the NHS did not vary by whether people were users or non-users in the last 12 months, suggesting that views are influenced by factors other than personal experience. (See 5.26)
These two questions (about the recent past and immediate future) produced broadly similar distributions to the 2000 data. However, the previous survey was even more negative about the past but more optimistic about the future. (See 5.29)
6. ACCESS TO SERVICES
The clear majority of users (79%) found physical access to the Out-of-hours service very or fairly easy, while the figure was even higher for the Primary Health Care Team (PHCT) surgery (c90%). Most users also found getting to sites for outpatient and inpatient services very or fairly easy (79% again). While disabled and older people found access to surgeries relatively difficult, this was not the case with regard to hospital-based treatment. (See 6.4-6.19)
Most of those attending as outpatients following a GP referral said that they had waited for less than two months for their appointment once the letter had been sent by their doctor. As with other services, the shorter the waiting time, the greater the satisfaction with the NHS. (See 6.14)
The majority of elective inpatients (62%) reported that they were admitted to hospital within three months of their name being put on the waiting list. (See 6.19)
7. CHOICE IN HEALTH SERVICE PROVISION
While most people were being offered a consultation with a health professional within 48 hours of making the request, a significant minority (especially for surgery visits) were waiting longer to see/talk to someone. More than a quarter of respondents (28%) requesting a surgery appointment with their own GP said that they had to wait for three days or more before being seen. However, it must be stressed that the percentage of patients being seen in primary care inside 48 hours of a request has risen by around 10% since 2000. (See 7.6, 7.9, 7.14 and 7.16)
Satisfaction both with the individual service and with the NHS overall was clearly associated with the rapid availability of appointments to see/speak to a health professional. A wait of three days or more tended to produce lower levels of satisfaction with the resulting contact. (See, for example, 7.6 or 7.10)
Only a quarter of those referred by their GP for an outpatient appointment said that the doctor had told them about different places they could attend. If patients discussed alternative sites with their GP, they were also more likely to have talked about waiting times. (See 7.20-7.21)
Similarly, just over a quarter (28%) of those referred by a GP were told by their doctor that they might be offered a choice of dates/times for an outpatient appointment. (See 7.22)
The situation was similar for elective inpatient admissions, though more people (37%) reported being told about a choice of dates or times for admissions. However, the majority of inpatients said that they felt that they had no choice at all in terms of the date and time of their admission. (See 7.29-7.30)
8. PUBLIC INVOLVEMENT IN THE DESIGN AND DELIVERY OF SERVICES AND THE RESPONSIVENESS OF THE NHS
A wide gap remains between the level of influence people think they should have over how the NHS is run and the influence they feel they have in practice. Three quarters of the overall sample said that members of the public have little or no influence over the way that the NHS is run - in contrast, 86% of people thought that the public should have at least some say over the running of the health service. There are various initiatives under way to increase opportunities for public involvement. (See 8.3-8.6)
A third of users said that they wanted to pass comment on the service they had received from the NHS in Scotland - these views were split quite evenly between positive observations and negative comments. There was little variation in terms of positive comments by age or sex but negative views were more common among those in bad health, people with disabilities and women aged under 55. (See 8.7-8.8)
Four in ten of those who considered making a negative comment actually did so, representing about 6% of all NHS users in the sample over the last 12 months. This feedback was generally given verbally and was informal - only 1% of users of the health service in Scotland had made a formal complaint in the previous year. Views were polarised in terms of satisfaction with the way in which informal complaints were handled and the same applied to satisfaction with the outcome of the complaint. (See 8.9-8.15)
Of the 6% of the sample who had given negative feedback, by far the most common cause was concern over waiting times (38%). (See 8.16)
While only a minority of those who considered making a complaint actually did so, three-quarters of those who had wanted to make a positive comment did so, almost 10% of all NHS users in the sample. The main means of passing a positive comment was simply by saying thank you to members of staff. (See 8.18-8.19)
9. ASPIRATIONS FOR IMPROVEMENT
Users of each service area were asked about the extent to which a (prompted) list of aspects of the service or facilities needed to be improved. Some of the items were specific to individual sectors (e.g. food in hospitals) but many were examined across the range of main NHS services in Scotland (e.g. the case knowledge of the professional or being treated with dignity). (See 9.1-9.3)
Significant numbers of users of the Out-of-hours service identified a need to improve convenient car parking and child friendly facilities. About a third of users wanted to see improvements to the speed of receiving test results, the knowledge of the health professional with regard to their situation and encouragement of patients to ask questions. (See 9.4-9.9)
Patients who had had a telephone consultation with someone from their local surgery in normal working hours also wanted improvements in having someone available to call them back at convenient times (over 40% of users) and almost as many people wanted it made easier to get through to the health professional in question. (See 9.10)
More than half of those questioned about seeing a professional at their local surgery wanted more convenient appointment times and over a third thought that there should be improved access by telephone. A third of these surgery visitors wanted improvements to car parking and also to their own understanding of the information they were given about their condition or treatment. (See 9.11-9.12)
Where service users had seen a GP other than their own they identified a greater need for improvements across all facilities and aspects of service than if they had seen their own GP or a Practice Nurse. This may have implications for how people perceive initiatives intended to increase access and choice. (See 9.13)
Those receiving home visits identified a need for improvement in the professional having enough knowledge of the patient's situation (39%) - this may be related to the fact that patients rarely saw their own GP in these circumstances. Other areas for improvement were about being given enough information regarding treatment and having enough time with the professional. (See 9.14)
More convenient car parking (52%) and appointment times (56%) were the main issues highlighted by outpatients, followed by improvements to the speed of test results (37%), child-friendly facilities and communication such as being given information about treatment. (See 9.15-9.16)
Large minorities of inpatients identified a need for improvements to public transport services for visitors to the hospital (45%) and also more choice over what patients eat (40%). Over a third of this sample (36%) thought that there was a need to improve disabled facilities and also the choice of when patients have their meals. Other areas for improvement of inpatient services included faster test results (29%) and having enough time with the professional (also 29%). (See 9.17- 9.18)
Viewed across the NHS as a whole, there were consistent calls for improvements to car parking (an average of 40%) and getting through by telephone (37%). In addition to these concerns over aspects of access to services, significant numbers wanted to see faster test results and improved communication such as better information about treatment, more useful information and encouragement to ask questions. (See 9.19-9.23)
KEY MESSAGES FROM THE RESEARCH
The satisfaction levels shown in the 2004 survey are high in respect of the individual service areas - they have not dropped at all over the last four years and in the case of Primary Care and inpatients, have actually risen since the 2000 study. However, satisfaction with overall use of NHS services is rather lower than might be expected from the headline figures for each service area and it is apparent that factors other than direct experience of the health service are influencing attitudes. It is younger users who continue to hold more negative views, perhaps because they have different expectations about service delivery.
Satisfaction is clearly linked to a number of factors, notably waiting times - the shorter the wait (for any kind of consultation or appointment or admission), the higher the level of satisfaction, both with the individual service and with the NHS as a whole. The increase in the number of people getting access to Primary Care inside 48 hours may explain the rise in satisfaction with this aspect of the health service since 2000.
Where choice, including rapid access to a health professional, is made available, patients are showing higher levels of satisfaction with the NHS. However, levels of awareness of choice in the health service in Scotland appear modest, notably for patients being referred from Primary Care to outpatient and inpatient services.
Under the modernisation agenda, the survey shows the increasing level of contact that patients have with nurses, notably in Primary Care - this contact generated high levels of satisfaction among service users.
Areas for improvement to services tended to relate most commonly to issues of access, notably convenient appointment times but also to the need for improved communication between health professionals and patients.
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