There is consistent evidence across settings of the important contribution that the patient–
practitioner relationship can make to satisfaction.
Detailed investigations confirm that patients
TABLE 26 Summary of studies investigating the effect of organisational features on satisfaction ReferenceCountryContextNo.responsesData OrganisationalMain findings Designcollectionfeature investigated 294 Ben-Sira,1990IsraelTheoretical1,026InterviewFFS vs salaried physicians FFS characterised by significantly more trust in physician,more Observationalemployed by central organisationhumaneness and committed doctors,greater appreciation of technical competence,and higher satisfaction 301 Calnan et al.,1993UKEmpirical1,688MailRelationship between satisfactionSubscribers less satisfied with NHS than non-subscribers,but Observationalwith NHS and having private membership was primarily because it was a job-related perk medical insurance 300 Corney,1999UKEmpirical120MailGP fund-holding vs non-fund-holdingNo significant differences in satisfaction or willingness to Observationalchange practices (Natural experiment)Waiting times for referrals and appointments lower in fund-holding 305 Davis et al.,1995USAEmpirical1,000TelephoneFFS vs managed care (HMO)Overall satisfaction significantly higher in FFS than HMO ObservationalFFS more satisfied on choice,access,waiting HMO more satisfied on costs,paperwork,preventive care HMO lack of choice related to lower satisfaction Respondents rated physicians more highly than plans Etter and Perneger,SwitzerlandPragmatic720MailPrimary care gatekeepers vs Patients consulting specialists more satisfied overall,and with 250 1997Observationaloutside specialistsaccess and technical aspects of care (Natural experiment) Fox and Storms,USATheoretical2,582TelephoneRegular source of careSatisfaction related to having personal physician and regular source 297 1981Observationalof care 202 Gray,1980USATheoretical821TelephoneFFS vs prepaid planFFS more satisfied on quality of care,courtesy,follow-up and Observationalpersonal interest of physician Halpin SchaufflerUSAEmpirical5,432MailFFS vs HMO vs mixed modelGreater satisfaction with physicians in FFS than HMO 270 et al.,1996Observational Hjortdahl and NorwayEmpirical3,044MailFFS vs salaried physiciansFFS more satisfied 280 Laerum,1992Observational Holloway et al.,USAEmpirical1,142Questionnaire FFS vs prepaid planNo difference between prepaid plan and FFS for satisfaction, 292 1989Observationalin clinicpersonalised care,quality of care Hsieh and Kagle,USAEmpirical401MailFFS or prepaid planFFS more satisfied with physician conduct 194 1991ObservationalPrepaid more satisfied with financial cover,less satisfied with access continued 65
66 TABLE 26 contd Summary of studies investigating the effect of organisational features on satisfaction ReferenceCountryContextNo.responsesData OrganisationalMain findings Designcollectionfeature investigated 302 Hulka et al.,1971USAEmpirical254InterviewInsurance vs no insuranceOverall satisfaction related to having a regular doctor and Observationalhaving insurance 303 Hulka et al.,1975USAEmpirical1,713InterviewAttitudes to healthcare systemPositive attitudes associated with regular physician and Observationallong relationship 312 Kralewski et al.,1988USAEmpirical1,014InterviewHMO vs FFS vs HMO/FFS mix vsSatisfaction levels high over all aspects,regardless of type of plan Observationalgovernment (Medicare)HMO most satisfied with cost,less satisfied with doctor–patient relationship and choice Mirowsky and Ross,USATheoretical1,197Interview and FFS vs not FFSSatisfaction high if FFS and have personal physician 205 1983Observationalquestionnaire Mummaleneni and USATheoretical2,891MailFFS vs HMOsOverall satisfaction highest for FFS 306 Gopalakrishna,1997ExperimentalHMOs rated as inferior on availability of specialists and hospitals, and superior on cost FFS inferior on waiting time and emergency care Voluntary HMO members more satisfied than those ascribed to HMO 309 Murray,1987USAEmpirical447Review ofFFS vs prepaid planNo difference in overall satisfaction with access,availability, Observationalrecordscontinuity (Natural experiment)FFS more satisfied on humaneness dimension 315 Perneger et al.,1996SwitzerlandEmpirical1,027MailSalaried gatekeepers vs FFS in Overall satisfaction ratings (after removing confounding factors): Observationalmanaged care organisation vs FFS in 72.7%,77.6%,80.8%,78.8% respectively private practice vs hospital outpatient Gatekeeping worst for 5 of 7 dimensions salaried residentsGroup differences not significant for satisfaction with physician time and explanation Pernerger et al.,SwitzerlandEmpirical814MailPatients moving from indemnity Managed care joiners’ satisfaction fell over 1 year,particularly 314 1996Observationalinsurance to managed carethose in gatekeeper arrangements (Natural experiment) 207 Ross et al.,1981USATheoretical376InterviewPatients moving into managed carePeople joining managed care had low satisfaction,although not Observationalbased on experience This is revised over time,after good experiences in managed care continued
TABLE 26 contd Summary of studies investigating the effect of organisational features on satisfaction ReferenceCountryContextNo.responsesData OrganisationalMain findings Designcollectionfeature investigated Ross Davies et al.,USAEmpirical2,013Questionnaire FFS vs HMOThose choosing HMO were as satisfied as FFS counterparts 307 1986Observationalin clinicPeople assigned to HMO were less satisfied Factors favouring HMOs:cost,office waiting Factors favouring FFS:length of appointment wait,availability of hospitals,continuity of care Rossiter et al.,USAEmpirical3,091TelephoneFFS vs HMO (Medicare beneficiaries)HMO enrolees more satisfied with waiting times and claims 310 1989Observationalprocessing,less satisfied with professional competence of (Natural experiment)providers and willingness of staff to discuss problems 308 Rubin et al.,1993USAEmpirical17,671Questionnaire FFS vs prepaidFFS rated higher Observationalin clinic Schmittdiel et al.,USAEmpirical10,205MailChoice of physicianPeople choosing own physician significantly more likely to record 313 1997Observationalsatisfaction as good–excellent 311 Stein et al.,1989USAEmpirical100InterviewHMO vs FFSFFS higher satisfaction on doctor–patient relationship (doctor is Observationalfamiliar and caring),convenience of care and choice HMO more satisfied on cost,less satisfied on doctor–patient relationship and choice Weiss and Ramsey,USAEmpirical400InterviewRegular source of careArrangements giving regular source of continuity of care 304 1989Observationalassociated with higher satisfaction FFS,fee-for-service;HMO,health maintenance organisation 67
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appreciate a personalised approach and affective behaviour. They seek a physician who can listen, will provide information and feedback, and whose behaviour emphasises shared decision-making.
There is also evidence that, where choice exists, care provided under FFS arrangements generates greater satisfaction than that delivered through prepaid schemes. Consumers registered with health maintenance organisations report greater satisfaction, mainly on cost and billing dimensions.
Gatekeeping arrangements give rise to poor satis-faction scores on access and choice dimensions.
Choice is positively associated with satisfaction.
Underlying these findings is a presumption that physician behaviour is affected by systemic incentives. If, for example, managed care remuneration arrangements constrain the time physicians spend with patients, or their ability to refer, this may impact negatively on the patient–
provider relationship and on patient satisfaction.
On the other hand, if FFS financing encourages physicians to engage in more affective behaviour, this may have a positive effect on reported satisfaction.294There is evidence from UK general practice that both patients and doctors prefer more time for consultations because more issues can be addressed. The cost-effectiveness of different lengths of consultation has not been explored.
Further research
Although both the patient–practitioner relationship and the means of healthcare financing are
important influences on satisfaction, the links between these two features remain to be fully investigated. Research is required into the implications for patient care and outcomes of alternative means of financing and organising healthcare, and on how different incentive structures impact on physician behaviour. This is particularly important given the current worldwide interest in healthcare reform in the face of rising costs and resource constraints.
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Introduction
The development of a consumer orientation in the NHS and the market basis of the US healthcare system have, in separate ways, focused attention on users’ views of healthcare. This has become manifest in a surge of publications in the last decade. A synthesis of the existing state of knowledge is timely, to inform future policy making, to identify research needs, and to offer guidance to the ever-increasing number of investigators seeking to measure satisfaction for one reason or another and in a variety of contexts.
The aim of this review was to provide evidence-based guidance for practitioners and managers in the healthcare arena. It focused on methodological issues to inform those wishing to elicit the views of healthcare consumers about the services they offer, and on the determinants of satisfaction. It sought to distinguish the effect of health service factors (policy variables) on satisfaction in different settings, and the extent to which sociodemo-graphic and other individual factors, over which suppliers have limited control, may influence evaluations. The review also aimed to identify gaps in current knowledge that could be addressed by future research efforts. These are discussed in the text that follows, and are summarised in Box 2 in the order in which they are introduced.
The review method and its main findings and recommendations are summarised in the next section, which is followed by discussion of the implications of the review for the NHS and the main stake-holders (managers, practitioners, public policy analysts and politicians, and users).
Concluding issues on consumer evaluations are raised in the final section.