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CHAPTER FIVE. SATISFACTION WITH SERVICES

5.1 Levels of satisfaction are one of the key headline measures from this survey and can be seen as a general summary of views of NHS services. The interview included scaled questions addressing satisfaction with individual service areas and overall use of the NHS in Scotland and also examined general views on the recent past and anticipated immediate future performance of the health service. However, the high levels of satisfaction reported here should be considered in the context of the areas for improvement identified by the patients interviewed in this survey - see Chapter 9. Satisfaction also included examination of coordination of healthcare for patients using outpatient and inpatient services.

Satisfaction with individual services

Out-of-hours service

5.2 A series of questions relating to satisfaction were included for each of the six NHS service areas covered in the questionnaire. Satisfaction was high in respect of the Out-of-hours service, with more than half of users (54%) pronouncing themselves "very satisfied" with the service provided - a further 34% were fairly satisfied. About one user in ten said that they were fairly or very dissatisfied with their experience of the Out-of-hours service. There were no differences in views by age and most of the other demographic sub-samples were too small to yield robust results for this service. However, the multivariate analysis showed a positive link between increasing age and higher levels of satisfaction. Moreover, that analysis also showed that those responding "didn't have to wait" were much more likely to be "very satisfied" with the Out-of-hours service - the same applied to patients who said that "someone came to (my) home".

5.3 Of the 29 people who were dissatisfied with the Out-of-hours service (out of 317 users), five said this was because of poor quality or inadequate treatment and four said that they had a long wait until they were seen by medical staff.

Telephone consultations

5.4 Satisfaction was also high among those who had experience of using telephone consultations with a health professional from their local surgery - six out of ten users were very satisfied with this contact and a further three in ten were fairly satisfied.

5.5 The sample of users was again quite small so there is limited demographic analysis that can be carried out for satisfaction with telephone consultations. However, a greater proportion of women users (66%) were very satisfied than was the case with the men who had used this service (51%). Here, the multivariate analysis showed a positive link between increasing age and high levels of satisfaction and also that those offered a consultation inside 48 hours were much more likely to report being "very satisfied" with this contact.

Primary Care - own GP

5.6 The level of satisfaction with surgery-based consultations with the respondent's own GP was high - 62% of users said that they were very satisfied and another 31% were fairly satisfied. Only 4% of those who had seen their own GP were dissatisfied with this contact. There were few significant demographic differences, even with a relatively large sample of people who had seen their own GP at the surgery. However, both standard tabulations and the multivariate work showed that satisfaction was lower among those who had to wait more than 48 hours for an appointment, and the multivariate analysis also demonstrated a higher level of satisfaction among older patients.

5.7 The 2000 survey had a different structure to the 2004 research in terms of contact with Primary Care - four years ago, there was no separate analysis for GPs and nurses. However, because most of the contact in 2000 was with the respondent's own GP, it is possible to make general comparisons between the two Scottish surveys. While the overall satisfaction score of 93% for contact with the respondent's own GP was similar to the 90% recorded in 2000, there has been a marked increase in the percentage who were very satisfied, up by 8% over the last four years. The latest Scottish results can also be compared with the 2003/04 Department of Health survey data for England - the latter showed, from a broadly similar question, that 84% of users were satisfied with their last GP visit.

5.8 There were only 29 people (out of 686 questioned) who said that they were dissatisfied with the service provided by their doctor. The two most common reasons for dissatisfaction were concerned with poor quality/inadequate treatment (9 cases) and difficulty in getting a convenient appointment time (8 cases).

Primary Care - another GP from the surgery

5.9 Just over 180 people were asked about their contact with another GP (i.e. not their own doctor or a locum) at the surgery. The satisfaction scores were almost as high for these doctors as for the respondent's own GP - 59% were very satisfied with this contact while 31% were fairly satisfied. The multivariate analysis showed that older patients were more likely to be very satisfied with this contact than were younger people and that higher satisfaction was recorded for those who waited less than 48 hours to see the GP. Among the patients who saw another GP, 9% were dissatisfied with the contact but no single reason emerged to explain the dissatisfaction.

5.10 Despite the high satisfaction scores for seeing other GPs, analysis of aspirations for improvements (see Chapter 9) indicated that people were more likely to identify greater need for improvements in service and facilities overall when they saw another GP compared with their own GP or a Practice Nurse.

Primary Care - Practice Nurse

5.11 Almost two-thirds of the people questioned about seeing the Practice Nurse said that they were very satisfied with the service provided - this was the highest overall satisfaction level recorded for any of the services covered in this Chapter. As more than a quarter were fairly satisfied, the combined satisfaction score was 93%. Satisfaction, though still high, was somewhat lower among younger patients, for example, only 50% of those aged under 35 were very satisfied compared with over 75% of people aged 55 and over - see Table 5.1 - and this was confirmed by the multivariate analysis. People were more likely to be very satisfied if they had a wait of less than 48 hours for the appointment, and people in social classes ABC1 were more likely to be very satisfied than respondents from blue-collar households.

Table 5.1: Overall, how satisfied or dissatisfied were you with the service provided during this visit?

Base: all questioned about seeing the Practice Nurse = 876

5.12 Among the 28 people (out of 867 users) who were dissatisfied, reasons for dissatisfaction included poor quality treatment (6 cases), difficulty arranging an appointment (five), problems in getting through to the surgery (four) and the nurse not having enough knowledge of their situation to deal with them effectively (also four cases).

Home visits

5.13 Those respondents who had received a home visit from a health professional expressed very widespread satisfaction at the service most recently provided - 69% were very satisfied and 22% fairly satisfied with only 6% (or 11 out of 247 users) dissatisfied. The multivariate analysis demonstrated that women patients and older people were more likely to be very satisfied than the men or younger people who received a home visit.

Outpatient visits

5.14 The satisfaction levels for outpatient services were lower than those for Primary Care services. However, most users (53%) were very satisfied with their last visit and a further third were fairly satisfied, giving an overall satisfaction figure of 86% - this figure almost mirrors the result from the 2000 research. A Department of Health survey in England in 2003/04 recorded an 81% combined satisfaction figure among a rather smaller sample of outpatients. Some 8% of the 2004 outpatients said that they were dissatisfied and analysis suggests that these tended to be younger service users - see Table 5.2. However, the 33% very satisfied figure for the under-25s is 9% higher than that recorded in 2000. Older patients were more likely to be very satisfied with the outpatient visit as were those who reported that physical access was very or fairly easy.

Table 5.2: Overall, how satisfied or dissatisfied were you with the service provided during this visit?

Base: all outpatients = 856

5.15 Again, there was evidence of a link between satisfaction and waiting times for outpatient appointments. Analysis showed that 90% of those seen inside a month of referral were very/fairly satisfied with the service provided, compared with 85% of those waiting for 1-3 months and only 77% of people waiting for over 3 months. Indeed, 24 of the 72 people who were dissatisfied with the outpatient appointment said that this was because of the waiting time or the difficulties in getting an appointment. The other relatively common criticism was about poor quality treatment, mentioned by 12 of the people who were dissatisfied with the service provided.

5.16 People who attended an outpatient appointment were also asked about whether they felt that the experience was clear and coordinated so that they didn't experience any unnecessary delay or repeat visits. A large majority of patients (84%) felt that the visit was well coordinated but nearly one in six (15%) said that there was a problem in this respect. Younger patients were less satisfied with this aspect of NHS service provision - see Table 5.3. There are more risks of problems in coordination when a patient needs to use more than one tier of NHS services as part of the same health episode - the data analysis therefore examined the views of people who had experienced Primary Care and an outpatient appointment and also an inpatient admission (i.e. they used three different NHS services). Encouragingly, there was no evidence to suggest that this group felt that the process was less joined-up than other users of outpatient facilities.

Table 5.3: Would you say that the outpatient process was well co-ordinated so you didn't experience any unnecessary delay or repeat visits?

Base: all outpatients = 856

5.17 The 133 people who felt that the process was not well co-ordinated were asked why they felt this to be the case. The most common complaint was to do with waiting times (40%) though many other factors were mentioned including too many visits/too much passing around (15%), late results (12%) and poor communication/explanation.

Inpatient admissions

5.18 The levels of satisfaction for inpatient admissions were higher than those for outpatient services, with 62% of patients being very satisfied with the service provided the last time they were in hospital. A further 28% were fairly satisfied, while 7% of this sample was very or fairly dissatisfied. For inpatients, there were no significant differences by age or sex, although emergency admissions generated a higher level of dissatisfaction (11%) than elective cases (4%). The 33 patients who were actually dissatisfied with their inpatient experience were asked why this was the case - almost half of this group mentioned poor quality treatment by medical staff.

5.19 There has been a clear increase in satisfaction with inpatient experience since 2000, when 50% of patients were very satisfied, with a rise of 12% over this period. The overall satisfaction score also rose from 81% to 90%. As a further comparison, the 2003/04 Department of Health survey in England had an overall satisfaction score of 77%, though from a smaller sample of inpatients.

5.20 Inpatients admitted as elective cases were asked about the coordination of their admission to hospital. The level of satisfaction with coordination was significantly higher than for outpatients with 93% saying that the process was well co-ordinated so that they knew what would happen next and why. People who had used Primary Care, outpatient and inpatient services as part of the same health episode felt that the process was as well joined-up as other inpatients. In total, only 17 people out of 242 thought that the process had not been well co-ordinated.

Overall satisfaction with NHS services used in the last 12 months

5.21 The entire sample of people who had used at least one NHS service in the last year was asked about their satisfaction with all of the services they had used over the previous 12 months. These results are perhaps best viewed in the context of a summary of satisfaction with the six main service areas. The combined satisfaction figure for overall NHS service use was 85% (i.e. very plus fairly satisfied), a score which is only slightly lower than some of the results for the individual service areas. However, as Figure 5.1 shows, far fewer people pronounced themselves very satisfied with the NHS overall than with any individual service area.

Figure 5.1: Satisfaction with NHS services

Base: All who were asked about each particular service = 207 to 876

5.22 Younger people were much more likely to be less satisfied than the older patients - see Table 5.4. There are no gender differences and social class does not seem to be a factor here.

Table 5.4: Overall, how satisfied are you with all of the NHS services you have used in the last 12 months?

Base: all outpatients = 1937

5.23 We have already seen how the levels of satisfaction with the individual service areas are uniformly high. However, it is worth noting that overall views may be informed by factors other than personal experience of each NHS contact - these factors can include anything from waiting times to media coverage of the health service in Scotland. There is also evidence from other 'user' research (the Best Value User Satisfaction Survey, or BVUSS, 2003/04, conducted in England for the Office of the Deputy Prime Minister) that overall satisfaction with some service providers is lower than satisfaction with individual public services. The BVUSS for 2003/04 had an average overall satisfaction figure for all local authorities of 55% but average scores for the individual services such as waste collection, libraries and parks and open spaces were in the range of 60-84%.

5.24 There was no equivalent question asked on the 2000 survey, hence there is no directly comparable data from within Scotland. The Department of Health research in England also does not have comparable data but its 2003/04 survey shows that overall views of the NHS are less positive than satisfaction with individual services.

Attitudes towards the NHS in Scotland in the last few and next few years

5.25 While many people (45%) thought that the NHS in Scotland had stayed about the same over the last few years, others felt that things had got better (20%) or worse (27%) over this period. Those who thought that there had been an improvement tended to be at the very top or very bottom of the age spectrum - the people aged 25-64 were more likely to feel that the NHS had got worse recently. Women (especially those aged 35-54) were generally more negative than men - see Table 5.5. Even allowing for the modest sample size, people living in small remote towns were notably critical of the NHS in recent years - 40% said it had got worse while only 14% thought there had been a positive shift. There was no significant difference between the views of users and non-users of NHS services, suggesting that the perceptions of most people are affected by other factors in addition to their own, generally positive, personal experience.

Table 5.5: Overall, when you think about the NHS over the last few years, would you say it has been getting better, worse or staying about the same?

Base: All = 2600

5.26 By contrast, there is more optimism with regard to the future performance of the NHS in Scotland - rather more people expect things to get better (39%) than are anticipating a deterioration (23%), giving a net positive score of 16%. The youngest and oldest respondents were the most optimistic and optimism was also higher in the more deprived areas than in the least deprived parts of Scotland. The most pessimistic sex/age group was again women aged 35-54 and those living in small remote towns were also less optimistic.

Table 5.6: And thinking about the NHS over the next few years, do you expect it to get better, worse or stay about the same?

Base: all = 2600

5.27 By amalgamating data from the two questions about the past and the future, there is a longer time perspective for all respondents - this identifies, for example, people who felt that the NHS had stayed the same for the past few years but would improve in the future. This group (labelled "Turned the corner") and four others cover most of the sample, as shown below in figure 5.2.

Figure 5.2: Expectations of NHS

Base: all = 2600

5.28 The most positive group in the figure above ('getting better all the time') included a relatively high proportion of men aged 65+. The most negative classification had a significant number of women aged 35-54, while the 'turned the corner' group included a substantial number of the under-25s.

5.29 Comparisons can be made with the data from 2000. The general pattern is the same on the two surveys with a negative net score in respect of the past but a net positive view for the future. However, while the 2000 sample was more negative about the past (-17% net) than the 2004 respondents (-7% net) it was actually more positive about the future (+22% compared with +16%) - see Figure 5.3. The Department of Health's 2003/04 survey in England used similar questions about the past and the future and also showed the same negative view of the recent past (-12% net) along with more positive expectations for the future (+7% net).

Figure 5.3: Net scores for the past and future in 2000 and 2004

Base: all = 2600 (in 2004) and 3052 (in 2000).

Summary

5.30 The satisfaction scores with the individual service areas are high and more people expected improvement in the future than anticipated a decline in NHS services. There is no evidence of a decline in the levels of satisfaction since 2000 and there has been a real improvement in respect of contact at the surgery and inpatient admissions. Telephone consultation had comparable satisfaction levels with most other services. In practice, it may be difficult to significantly increase service satisfaction from some of the levels shown here - however this report highlights the higher scores when people do see the right person in the right place at the right time. Possible improvements to services - see Chapter 9 - suggest that some things could be done to further enhance overall views of the health service in Scotland.

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