Assessment of patient experience of NHS primary care services
Submitting InstitutionUniversity of Manchester
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Economics: Applied Economics
Summary of the impact
Improving patient experience of health services is a policy priority
worldwide. The University of
Manchester (UoM) has conducted research on patient experience since 1995,
leading to the
development of a series of validated measures for assessing patient
experience of quality of care
in primary care, including access to care and the degree to which services
are patient-centred. Our
measures have been in routine use in the NHS since 2004, sent to samples
of several million
patients. The data have been used to provide incentives for the highest
quality practices, and to
inform policy makers about current care throughout the UK.
See numbered references in section 3.
The impact case is based on research that took place at the UoM from
2000-2011. The research
was conducted by the National Primary Care Research and Development Centre
Department of Health-funded policy research unit at the UoM. The key
Peter Bower (Professor of Health Services Research, 1995-date)
Stephen Campbell (Professor of Primary Care Research,
Sudeh Cheraghi-Sohi (Research Fellow, 2004-date)
Nicola Mead (Research Fellow, 1999-2010)
David Reeves (Reader in Statistics, 2001-date)
Martin Roland (Professor of General Practice, 1992-2009)
A key aim of NPCRDC was to develop methods to assess and improve quality
of care for patients
in primary health care settings. Quality of health care for individual
patients can be judged in terms
of ready access to care, and the effectiveness of care once it is
accessed. Although scientific
evidence and clinical consensus are both important methods of determining
quality, there is
increasing agreement that a comprehensive assessment of quality needs
consideration of the
views and experience of patients.
However, reliable, valid and useable assessments of the patient
experience have not always been
available, which has meant that the patient voice has been largely missing
from the quality
Our work involved multidisciplinary research on theory, in-depth
qualitative work with patients, and
large-scale quantitative evaluations. Key contributions are detailed
- We defined the core dimensions of patient-centredness (1).
- We investigated how patients make judgments about quality of care,
dimensions they can judge effectively, and those (such as clinical
quality of care) that may
be better assessed by other quality improvement methods (2). We also
relative priority that patients place on different aspects of care (3)
to help decision-makers
respond more effectively.
- We designed a series of measures to provide reliable and valid
assessments of patient
experience of care. We progressively tested and refined these measures,
empirical and psychometric validation work, ending in the development of
Practice Patient Survey (GPPS) (4).
- We used our measures in a series of high impact research studies
exploring quality of care
in primary care and the determinants of quality. This approach enabled
us to better inform
policy makers about current deficits in care as experienced by patients.
For example, we
demonstrated the mismatch between the expectations of patients and
policy makers for
standards of service in general practice (5). Following the introduction
of a world-leading
pay-for-performance scheme in the UK (the Quality and Outcomes
Framework, or QoF),
and consequent improvements in the quality of clinical care, we also
patient experience of continuity of care was worsening over time (6).
- We worked closely with policy makers at the Department of Health to
develop methods to
use the products of this research programme within new incentive systems
to drive improvements in quality of care.
References to the research
1. Mead N, Bower P (2000). Patient-centredness: a
conceptual framework and review of the
empirical literature. Social Science & Medicine 51:1087-1110.
2. Chapple A, Campbell S, Rogers A, Roland M (2002).
Users' understanding of medical
knowledge in general practice. Social Science & Medicine
3. Cheraghi-Sohi S, Hole A, Mead N, McDonald R, Whalley
D, Bower P, et al (2007). What
Patients want from Primary Care Consultations. A Discrete Choice
Experiment to Identify
Patients' Priorities. The Annals of Family Medicine 6:107-115.
4. Campbell J, Smith P, Nissen S, Bower P, Elliott M, Roland
M (2009). The GP Patient
Survey for use in primary care in the National Health Service in the UK -
psychometric characteristics. BMC Family Practice 10: DOI:
5. Bower P, Roland M, Campbell J, Mead N (2003).
Setting standards based on patients'
views on access and continuity: secondary analysis of data from the
assessment survey. BMJ 326:258. DOI:
6. Campbell S, Reeves D, Kontopantelis E, Sibbald B, Roland
M (2009). Effects of pay for
performance on the quality of primary care in England. The New England
Medicine 361:368-378. DOI: 10.1056/NEJMsa0807651
Details of the impact
See numbered corroborating sources (S) in section 5.
Traditionally, assessment of quality of care in health services has been
limited to professional
perspectives, with little central collection of data and minimal
consideration of patient perspectives
on service delivery. We ensured that patients were at the heart of quality
through the development, validation and implementation of measures of
patient experience, and
their adoption and collection on a national scale. Our impact has been to
raise the profile of patient
experience and link it to quality improvement activity across the UK.
Raising the profile of patient experience
Policy documents have highlighted the critical role of information on
patient experience. The White
Paper `Equity and excellence: Liberating the NHS' (S1) sought to
`encourage more widespread use
of patient experience surveys and real-time feedback' to inform choice and
The NHS centralised the use of standardised measures in the assessment of
patient experience in
2007-2008, sending our GPPS measure to samples of patients in a rolling
programme of quality
measurement. This has resulted in GPPS being completed by millions of
patients, with their views
assessed and analysed on a large scale and a sustained basis over time
Collection of data on patient experience is not simply for the benefit of
managers and policy
makers. All NHS patients can now access information on GPPS scores of
their local general
practices from a website (www.gp-patient.co.uk/faq/accessing/),
to help them assess the quality of
care and make choices about local services.
Linking patient experience to quality improvement
Much research has shown how simple provision of information is
insufficient for securing change.
To ensure appropriate impact from patient experience measures, in 2004,
use of one of our earlier
patient experience measures (GPAQ) was linked to payments in the early
version of the Quality
and Outcomes Framework (QOF).
The QOF represents a unique programme for quality improvement and the
results have been of
interest worldwide. Early in the development of the QOF, general
practitioners were incentivised to
conduct surveys on their practice population, and to respond to these
surveys with appropriate
quality improvement activities to enhance patient experience and ensure
that their services were
responsive to the needs of their local population. Between 2004 and 2009,
the vast majority of
practices (>90%) undertook such activities.
To support this activity and enhance value for money, we disseminated
written guidance for
practitioners to interpret the GPAQ data and use it to target these
quality improvement activities at
a local level (S3). Twenty three thousand copies of the guidance were
disseminated, to stimulate
and guide quality improvement across the United Kingdom.
Although initial incentives linked to patient experience were largely for
the use of surveys, later
versions of the QOF significantly raised the level of achievement
required. In 2009, £68 million
pounds worth of general practitioners' pay were linked to actual patient
reports of their ability to
gain ready access to care, such as getting an urgent appointment and being
able to book ahead
(S1). These targets were harder to meet, with around 70% of practices
performance on these more stringent targets between 2010 and 2012.
The national regulator, the Care Quality Commission (CQC) used patient
experience scores as
part of their performance assessment of Primary Care Trusts undertaken by
the predecessor of the
CQC (the Health Care Commission). Current CQC documentation includes
surveys as an indicator of standards to be expected of all GP practices
Department of Health reports list the other activities it has conducted
in response to the data
collected by patient surveys, including the GPPS (S6,S7). This has ranged
dissemination to encourage responsiveness of patient experience among
Primary Care Trusts,
review of the needs of marginalised groups such as ethnic minorities, and
establishment of teams
to respond to practices and PCTs with the lowest scores.
Sources to corroborate the impact
S1. Department of Health (2010). Equity and excellence: liberating
the NHS, The Stationery
S2. Roland M, Elliott M, Lyratzopoulos G, Barbiere J, Parker R,
Smith, P, Bower P, Campbell J
(2009). Reliability of patient responses in pay for performance schemes:
analysis of national
General Practitioner Patient Survey data in England. BMJ. 339:b3851.
S3. Carter M, Roland M, Bower P, Greco M, Jenner D
(2004). Improving your practice with
patient surveys. University of Manchester. NPCRDC/CFEP.
S4. Care Quality Commission (2010). Essential standards of Quality and
S5. Care Quality Commission (2013). What standards you have a right to
expect from the
regulation of your GP practice.
S6. Department of Health (2011). GP patient survey: guidance 2007/08 for
authorities, primary care trusts and GP practices.
S7. Data on the use of patient experience surveys by general practices
incentives within each year the Quality and Outcomes Framework can be