Family Practice Vol. 21, No. 2, 180-182
Family Practice Vol. 21, No. 2 © Oxford University Press 2004, all rights reserved.
Article |
The impact of a general practice co-operative on accident and emergency services, patient satisfaction and GP satisfaction
Medical Care Research Unit, a Sheffield Health Economics Group and b Institute of General Practice and Primary Care, School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
E-mail: d.m.pickin{at}sheffield.ac.uk
Received 8 April 2003; Revised 15 October 2003; Accepted 3 November 2003.
Pickin DM, O'Cathain A, Fall M, Morgan AB, Howe A and Nicholl JP. The impact of a general practice co-operative on accident and emergency services, patient satisfaction and GP satisfaction. Family Practice 2004; 21: 180–182.
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Abstract |
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Background. The advent of general practice co-operatives represented a fundamental change in the delivery and organization of out-of-hours services. Concerns have been voiced that co-operatives might impact adversely on workload in accident and emergency (A&E) departments.
Objective. The purpose of this study was to assess the impact of establishing a general practice co-operative on use of A&E services, patient satisfaction and GP satisfaction.
Methods. A controlled before and after study of a GP co-operative in Sheffield, UK was carried out. A postal questionnaire was sent to 26 911 people, 13 442 before and 13 469 after the opening of the co-operative, to determine service use, in particular A&E attendance, in the previous 4 weeks. Patient satisfaction was assessed through structured interviews with 653 patients. GP satisfaction was assessed using a postal survey of all 98 Sheffield practices 2 years after the opening of the co-operative.
Results. There was no change in the use of A&E services, odds ratio = 1.08 (95% confidence interval 0.60–1.94). There was no change in patient satisfaction overall, mean difference 0.02 (-0.32 to 0.36). Sixty-seven per cent of doctors in member practices were much more satisfied with out-of-hours duty compared with 10% in non-member practices (P < 0.001).
Conclusions. General practice co-operatives have been successful in achieving their policy objectives, improving GP morale without jeopardizing patient satisfaction or impacting adversely on A&E services.
Keywords. Accident and emergency services, family practice, out of hours, primary health care.
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Introduction |
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Comparisons of GP co-operatives with deputizing services have found equivalent or higher satisfaction among doctors,1 equivalent satisfaction among patients2 and lower rates of home visiting, prescribing and hospital admission.3 Other studies have found a decrease in GP stress levels and an increase in GPs' general health status following the establishment of co-operatives.4,5 These evaluations have not compared changes in practices joining co-operatives with changes in control groups. Concerns have been voiced that co-operatives might impact adversely on workload in accident and emergency (A&E) departments.6 We therefore undertook a controlled before and after study to examine the impact of a GP co-operative opening in Sheffield on A&E services, patient satisfaction and GP satisfaction.
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Methods |
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The co-operative
The co-operative opened in 1996. Prior to that, the vast majority of Sheffield GPs had used a commercial deputizing service. At the time of this study, the co-operative covered 67 practices, operated from a primary care treatment centre based at a city centre hospital, and offered a home visiting service.
Use of A&E services
In the month prior to the co-operative opening, a postal questionnaire was sent to a sample of the Sheffield population, randomly sampled from patients of GP co-operative members and randomly sampled at twice the rate from patients of non-members. We asked whether people had sought help for any health problem in the previous 4 weeks, and if so whether the contact was planned before seeking help or unplanned. Two reminders were sent and the survey was repeated a year later.
Patient satisfaction
Structured interviews were offered to those identified in the postal survey as having recently sought health care in an unplanned contact. We used Salisbury's adaptation of the McKinley questionnaire.7,8 We asked about satisfaction with the first service contacted, for those patients attending GP or A&E services.
GP satisfaction
Two years after the opening of the co-operative, we undertook a postal survey of all 98 Sheffield practices. One doctor from each practice was asked to assess, on behalf of their practice, the current level of satisfaction with their out-of-hours arrangements in comparison with the period immediately before the establishment of the co-operative. We used a 5-point Likert scale ranging from ‘much more satisfied’ to ‘much less satisfied’. Two reminders were sent.
Ethical approval for the study was obtained from the North Sheffield local research ethics committee.
Analysis
The primary outcome measure was the change in A&E use of patients of GPs who had joined the out-of-hours co-operative before and after its establishment, compared with similar changes in patients of other GPs in the city. Logistic regression was used to test for differences in the odds ratio for change in A&E use, based on the interaction between year and co-operative membership, adjusting for age, sex, distance to A&E and car access. Analysis of variance was used to compare changes in mean patient satisfaction scores, adjusting for age, sex and ethnic group. Chi-squared was used to test for differences in GP satisfaction.
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Results |
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Impact on A&E
The postal questionnaire was sent to 26 911 people, 13 442 before and 13 469 after the opening of the co-operative. Forty-one people had died and 1780 questionnaires were returned to sender, giving a response rate of 71.4% (17 908/25 590). Of respondents, 8.9% (1596/17 908) made unplanned health service contacts in the previous 4 weeks, 70% (1121/1596) being patients of member practices. There were no significant differences in sex, car access or distance to A&E before and after the co-operative was established.
The majority of unplanned contacts were with general practice (Table 1). The difference between changes in A&E use in member and non-member practices was not statistically significant. The adjusted odds ratio was 1.08 (95% confidence interval: 0.60–1.94, P = 0.81). When the analysis was restricted to out-of-hours contacts, no significant difference was found.9
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Impact on patient satisfaction
Of the 1596 patients who sought unplanned care in the previous 4 weeks, 653 gave consent and were available to be interviewed about satisfaction. No important differences were found in age, sex or ethnic group before and after the opening of the co-operative. Patient satisfaction scores were high in both years,8 3.86 (n = 243) before and 3.77 (n = 220) after for member practices, and 3.92 (n = 99) before and 3.81 (n = 73) after for non-members. There was no evidence that the change in patient satisfaction in member practices was different from that in non-members (difference in change of 0.02, 95% confidence interval -0.32 to 0.36, P = 0.86). A similar picture was found when the analysis was restricted to out of hours.9
Impact on GP satisfaction
Questionnaires were returned by 91% (89/98) of practices: 58 co-operative members, 29 non-members and two practices excluded because they had recently changed out-of-hours arrangements. A higher proportion of member practices than non-member practices reported being much more satisfied with out-of-hours arrangements since the opening of the co-operative, 67% (39/58) versus 10% (3/29), P = 0.001.
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Discussion |
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We have found that the establishment of a co-operative did not impact adversely on the use of A&E services. A dramatic improvement in doctor satisfaction was achieved without reducing patient satisfaction. This is the first study to address the impact of co-operatives on A&E services, and findings will be reassuring to A&E departments. The improvement in GP satisfaction is consistent with previous studies.1,4 Patient satisfaction with co-operatives was reassuringly high and slightly higher than in previous studies.2
A limitation of this study was that we did not use an experimental design. The before and after design used has limitations, principally that results may have been influenced by changes other than the opening of the co-operative. Nevertheless, we believe that the co-operative was the most important development influencing health service use locally in this time period and, since ours was a controlled before and after study, any other change would only confound results if acting differentially on member and non-member practices. In the study of GP satisfaction, we relied on practices' recall of satisfaction before the co-operative. Baseline data would have provided more robust evidence.
Primary care teams have been at the heart of instigating and delivering this change, rather than being the recipients of top-down service development. Future initiatives in primary care, such as the integration of GP co-operatives and NHS Direct, and the implementation of Advanced Access, may have much to learn from the way general practice co-operatives have been introduced.
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References |
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1 Salisbury C. Evaluation of a general practice out of hours cooperative: a questionnaire survey of general practitioners. Br Med J 1997; 314: 1598–1599.
2 Salisbury C. Postal survey of patients' satisfaction with a general practice out of hours cooperative. Br Med J 1997; 314: 1594–1598.
3 Salisbury C. Observational study of a general practice out of hours cooperative: measures of activity. Br Med J 1997; 314: 182–186.
4 Heaney D, Gorman D, Porter M. Self-recorded stress levels for general practitioners before and after forming an out-of-hours primary care centre. Br J Gen Pract 1998; 48: 1077–1078.[Web of Science][Medline]
5 Fletcher J, Pickard D, Rose J, Stewart-Brown S, Wilkinson E. Do out-of-hours cooperatives improve general practitioners' health? Br J Gen Pract 2000; 50: 815–816.[Web of Science][Medline]
6 Hallam L, Henthorne K. Cooperatives and their primary care emergency centres: organisation and impact. Health Technol Assesst 1999; 3 (7).
7 McKinley RK, MankuScott T, Hastings AM, French DP, Baker R. Reliability and validity of a new measure of patient satisfaction with out of hours primary medical care in the United Kingdom: development of a patient questionnaire. Br Med J 1997; 314: 193–198.
8 Salisbury C. Postal survey of patients' satisfaction with a general practice out of hours cooperative. Br Med J 1997; 314: 1594–1598.
9 Pickin DM. An evaluation of a general practice cooperative. MD thesis, University of Sheffield; 2001. http://www.shef.ac.uk/~scharr/mcru/reports/gpcoopmd.pdf (accessed January 2004).
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