Modelo de Contratación Propuesto - Resultados Obtenidos

8. Análisis de la inclusión laboral implementada por Alkosto

8.2. Resultados Obtenidos

8.2.2. Modelo de Contratación Propuesto

practitioners

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arts of this chapter are based on Farringtonet al.213_{under the terms of the Creative Commons}

Attribution license (CC BY 4.0), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/).

Abstract

Background

To date, little research has focused on doctors’attitudes to patient experience surveys that give them

personalised feedback. Although national surveys, such as the GP Patient Survey, report results at a practice level, GPs are additionally required to reflect on individual-level patient feedback for the purposes

of appraisal and revalidation. This chapter examines doctors’perceptions of patient experience surveys,

and the receipt of personal feedback from these, in primary care settings. Methods

We analysed data from 21 interviews conducted with GPs across 14 practices. Participants were sampled

from doctors who had participated in our patient experience survey (reported inChapter 9) and had

recently received individual-level survey feedback. Results

General practitioners expressed commitment to incorporating patient feedback in quality improvement

efforts. However, they also expressed negative views about the credibility of survey findings and patients’

motivations and competence in terms of providing feedback. As a result, they found it challenging to make sense of and take action as a result of the feedback that they received from patient experience surveys. Conclusions

General practitioners’ambivalence towards patient experience surveys is likely to limit their impact on the

success of quality improvement initiatives. In response, this chapter highlights the need for initiatives to

address doctors’concerns about the credibility of surveys.

Introduction and rationale

A number of recent policy initiatives have emphasised the utility of patient feedback for quality

improvement.38_{In the UK, a series of initiatives has established and expanded the role of patient experience}

surveys in the NHS, leading to the recent NHS Outcomes Framework,214_{which features patient experience}

as one of five key domains on which NHS performance is judged. In addition to national surveys, such as the GP Patient Survey, numerous surveys of various kinds are undertaken at the local level by health-care

providers.215_{In 2012, the General Medical Council (GMC) introduced a revalidation programme requiring}

individual doctors to collect patient feedback on the care that they provide.216_{Such feedback is}

subsequently used as supporting information in a 5-yearly procedure through which doctors‘revalidate’,

that is, retain their licence to practise, and is also intended to facilitate reflective improvements in the quality

of individual doctors’practice.137_{Nevertheless, most national survey programmes continue to be conducted}

and reported at the organisational level. Likewise, existing research has tended to focus on doctors’

engagement with reports of patient experience at the level of the hospital ward, primary care practice or similar organisational units within primary or secondary care.

Existing research highlights the importance that doctors place on patient experience in principle and the

potential for positive improvements based on patient feedback.119_{This body of work has also explored}

challenges surrounding the incorporation of patient feedback into medical practice. Doctors commonly express a range of negative views about the plausibility of survey findings, including concerns about sample size and representativeness; respondent bias and subjectivity; reliability and validity of survey instruments; lack of clarity on the purpose of surveys; contextual sensitivity; and the challenges of interpreting patient

feedback when lacking contextual information, with numerical scores viewed by many doctors as‘a simplistic

reduction from a complex range of factors’(p. e160)200_{(see also Coulter}_{et al.}45_{and Asprey}_{et al.}119_{). These}

challenges relate to long-standing critiques of quantitative surveys that highlight issues such as the lack of

self-evident meaning in numerical findings (see, for example, Williams217_{) in a range of contexts including}

special educational services and health-care provider performance.218,219_{These and other concerns have}

tended to limit the impact of patient feedback in terms of quality improvement.215

Many of the challenges associated with patient experience surveys relate to standard features of survey administration and so are also likely to be relevant to surveys administered at the individual doctor level.

With some exceptions (e.g. Hillet al.67_{), few researchers have focused directly on doctors}_’_engagement

with patient experience surveys at the individual doctor level. Although such engagement is largely

unexplored, it is of considerable significance given the well-established role of patient experience surveys in contemporary health care (and the NHS in particular) and the recent introduction of mandatory individual doctor-level surveys.

This chapter draws on qualitative data to explore attitudes towards patient survey feedback on the part of individual GPs. By exploring attitudes towards the plausibility of surveys, this chapter demonstrates the

generally contested, problematic and inconsistent nature of doctors’current engagement with patient

experience surveys and points towards the need for additional investment in training and relevant resources.

Changes to study methods from the original protocol

The aim of this strand of work, as stated in the original protocol, was to understand how general practices respond to low patient survey scores, testing a range of approaches that could be used to improve

patients’experience of care (aim 1).

The interviews reported here took place alongside the focus groups with practice staff, reported inChapter 7.

In our original application, we set out plans to interview each doctor in between five and eight low-scoring practices. These interviews would cover their accounts of what contributed to their practice score, considering their recent GP Patient Survey feedback. However, as with the focus groups, the conduct of our own patient

experience survey (reported inChapter 9) at individual doctor level meant that we were able to feed back

to GPs their own patient experience scores. Interviews thus considered attitudes to both practice- and

individual-level feedback. We also altered our sampling strategy, deciding instead to incorporate a wider range of practices (14 practices) to reflect a greater diversity of practice cultures within which the GPs were working.

Methods

Data collection

We conducted 40 semistructured face-to-face interviews with GPs in practices across Cornwall, Devon, Bristol, North London, Bedfordshire and Cambridgeshire. These practices were part of a larger group of 25

practices participating in our patient experience survey (seeChapter 9for details of sampling, recruitment

and survey conduct). From the sample of 25 practices, two doctors were interviewed from practices with low GP Patient Survey scores and one doctor was interviewed from each medium- and high-scoring

INTERVIEWS WITH GENERAL PRACTITIONERS

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practice. Individual GPs were identified randomly within each practice and approached one by one for consent to participate. Each GP had received an individual report from our patient experience survey, focused on patient responses to communication items and including summary statistics and free-text comments. An interview topic guide was developed in light of existing literature to focus on individual-level patient experience surveys and was revised in relation to policy changes on revalidation that occurred during the conduct of the study. Interviews lasted between 20 and 60 minutes.

For the purposes of this report we excluded 19 interviews conducted with GPs prior to the introduction of revalidation in December 2012, as this changed the nature of the topic guide and issues covered in the interviews in relation to the conduct and implications of individual doctor-level patient surveys. We thus include data from 21 GP interviews conducted across 14 practices.

Data analysis

The interviews were digitally recorded with written consent and transcribed verbatim. NVivo 10 software was used to organise and categorise the data. Transcripts from four GP interviews (not included in the final analysis) were used to develop an initial coding framework, which included 44 codes grouped into

headings including survey experience and survey-related change. A thematic analysis approach was used220

involving six distinct stages: familiarisation with the data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; and producing a final analysis, which was discussed among the research team before being revised and finalised.

Results

Dimensions of ambivalence

Our analysis found that GPs demonstrated profound ambivalence regarding the purpose and plausibility of patient surveys, leading to complex, varied and problematic engagement with patient feedback. The Oxford

English Dictionary221_{defines ambivalence as}_‘_{having mixed feelings or contradictory ideas about something}_’_{, a}

definition that was interpreted in this study as a spectrum from mixed feelings about something to holding ideas that directly contradict each other. Two main dimensions of ambivalence were identified. The first

relates to doctors’views of patients’motivations and competence as responders in surveys. The second relates

to doctors’views of surveys from the perspective of enabling quality improvement (or otherwise)–views that

may diverge from what is intended by the managers responsible for introducing and administering surveys. Interviewees rarely situated themselves consistently with regard to these two dimensions of ambivalence; indeed, it was common for GPs to express inconsistent and contradictory views on both dimensions of ambivalence, often within the same interview (see following sections). Consequently, although some themes (e.g. a greater emphasis on negative rather than positive views of patients) were more to the fore than others, ambivalence is the dominant and unifying feature of the findings in this area.

Patients and surveys

General practitioners emphasised the centrality of the doctor–patient relationship and the utility of

receiving feedback from their patients. For example, one interviewee described the doctor–patient

relationship as an‘adult to adult’relationship in which patients know more about some things than

doctors and in which doctors need to listen to patient feedback:

[T]he only way you’re going to know whether you’re doing your job properly . . . it’s listening to what the patients are telling you [in their feedback].

Against this backdrop, many GPs discussed patients’motivation and competence to provide feedback in

more detail. One GP discussed how patients’feedback showed that they were reflecting in depth on their

experience before communicating it through free-text comments:

They’re . . . thinking‘Well, actually, what do we think of the [practice]?’. . . rather than just at the time when they’re desperate for an appointment and frustrated, you know, to think actually . . . what things at the [practice] do they actually value.

GP9 More widely, several doctors noted that patients were used to responding to surveys in other spheres of their lives, potentially (although not inevitably) increasing their willingness to provide feedback on their health-care experiences. As such, many doctors saw patients as motivated to reflect on and communicate their experiences (although this was also raised as a concern in terms of raising patient expectations; see following section).

Similarly, some doctors expressed the view that patients are competent to judge their care. Patients’ability

to evaluate doctors was sometimes endorsed because it aligned with the doctors’pre-existing positive

views of their own professional skill. However, despite this, many interviewees expounded fundamentally ambiguous views of patients considered as survey respondents, often combining in the same interview

seemingly positive views of patients’motivation and competence with more negative views. For example,

one GP emphasised the utility of patient surveys in terms of patients’capacity to identify specific problems:

I think the patient feedback is really important . . . You’ve got to actually listen to what are patients saying, [e.g.] they are telling us through this [feedback] that the system currently in place for booking appointments . . . is not working for them.

GP2

The same GP also stressed, however, the ways in which patients’comments were often of little use for

improving care quality, especially at the individual doctor level:

When I read the comments it was just a diatribe of accusations against the practice as a whole . . . [I]n terms of my individual practice it gives me no feedback at all . . . [The] majority of the comments on the appointment system and on lack of [relational] continuity [were] all on the issues that we are totally aware of.

GP2

Doctors often questioned patients’motivations, first, by viewing patients who provided negative feedback

as doing so because they had specific grievances to express [‘if they’ve got an axe to grind’(GP10)] and,

second, by suggesting that patients participate in surveys to gain leverage over doctors. Many interviewees

also questioned patient competence or patients’ability to provide accurate and relevant feedback. Overall,

GPs advanced six principal characteristics of patients that singly and/or collectively undermined their ability to provide accurate feedback:

1. Positive bias–the tendency of patients to give strongly positive feedback regarding doctors, linked to

patients’well-documented reluctance to criticise doctors in general and their own GPs in particular.

In this context, one GP described the patients as‘quite reluctant to talk the doctor down, because

we’ve got a good ongoing relationship’(GP10).

2. Negative halo effects–patients ascribe negative characteristics to consultations because of other

negative experiences during their visit to the practice. As one GP described, patients may carry an‘initial

bad experience’with the practice reception‘all the way through . . . into the consulting room as well

. . . it affects all of your feedback’(GP6).

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3. Failure to understand surveys–for example one GP noted that‘because [patients] don’t understand the

questionnaire, they might tick whatever box they think; and that’s the reason we don’t get true

results’(GP19).

4. Subjectivity–several doctors emphasised that different individual patients could give different feedback

despite having experienced similar consultations concerning similar medical problems. More widely, one

GP highlighted patient subjectivity by suggesting that strongly negative patient feedback could‘reflect

more on the person [patient] than it does on you [the doctor]’(GP6).

5. Inability to evaluate clinical competence–GPs highlighted patients’inability to judge doctors’clinical

competence. As one noted, patients‘don’t know about my clinical ability . . . [or] how much I

know’(GP8).

6. ‘Good doctors, bad feedback’ –doctors felt that good care may result in negative feedback because it

differs from patients’preferences. Common examples included doctors refusing to prescribe antibiotics

or write‘sick notes’for patients with depression. GPs referred to situations in which patients were

unhappy with treatments recommended (or withheld) by doctors and often saw themselves as having a

responsibility to protect NHS resources rather than pleasing patients:‘pleasing a patient isn’t the same

thing as being a good doctor . . . I see part of my role as a GP [as] gatekeeping NHS resources,

including my own time’(GP8).

Thus, although doctors’views often combined positive and negative views of patient feedback, negative

views tended to dominate, resulting in a sceptical attitude that questioned patients’motivations and

competence vis-à-vis the provision of feedback (Table 29).

Patient experience surveys and quality improvement

This section focuses on a second dimension of ambivalence, relating to GPs’perceptions of the potential

for patient experience surveys to drive quality improvement. Doctors identified benefits in reflecting on patient feedback and encouraging competition between doctors through comparison of patient feedback scores. However, they also presented a number of concerns that undermined the potential of surveys to

facilitate quality improvement. As with doctors’attitudes towards patient feedback, the overall impression

was more negative than positive.

TABLE 29 General practitioners’attitudes to patients’motivation and competence