The IMPROVE team carried out detailed analysis on 2009 GP Patient Survey data to examine the variations between patients in different ethnic groups. This showed that certain patient groups reported more negative experiences of care than all respondents. These were minority ethnic patients (particularly those from Chinese and South Asian backgrounds), patients with poor self-reported health and younger patients. The research team saw variations in the survey scores for doctor-patient communication in these groups as a particular concern because this is such an important driver for overall satisfaction with care.
To explore this further, the researchers then did further analysis of the data from the 2012-2013 and 2013-14 years to see where the largest gaps in patient experience lie. A measure of GP-patient communication was built up from the five items that patients scored in that section of the questionnaire. They found strong evidence that the effect of ethnicity on reported GP-patient communication varied by both age and gender. In particular, older, female, Bangladeshi respondents reported significantly poorer experiences of communication than White British patients of the same age and gender, within the same practice. Chinese patients responding to the survey also reported more negative experiences of care compared with White British counterparts, this time across all age groups. Finally, the researchers also identified that younger (those aged under 55) ‘any other white’ patients also experienced disparities in their reported consultation experience, compared to White British patients.
The researchers were careful to consider the part that language proficiency might play in these results. They realised that the experience of some patients with poor language skills might not be captured at all, as they just wouldn’t complete the survey – even though the questionnaire is available in numerous languages. So, if language proficiency plays a part in how likely people are to respond to the survey, the survey may underestimate the consultation difficulties experienced by certain minority ethnic groups. The researchers encourage GPs to consider patients’ language challenges as a step in improving consultation experience.
“I’m not altogether surprised that some Asian patients reported dissatisfaction with their GP consultations. Some of the older Indian and Pakistani doctors can have a rather old-fashioned style of talking to patients. I think patients’ language skills must play some part in these results, too, as some of the first generation immigrants don’t have the language proficiency of their children and grandchildren. That is hard as you get older and need to use the NHS more. With the GPPS, we need to make sure we know what the data is saying and respond to the results.
"In my Patient Participation Group, we tend to use much of our time supporting the practice to make practical changes: make the lift more reliable, increase the phone lines, improve the training of front desk staff. But we also discuss the consultation data with our practice manager and one of the GPs, and they take the development points forward.”
Moinuddin Kolia, Community Pharmacist and Chair of the Patient Participant Group in a central Leicester practice.
Further work followed up the disparities in the experience of South Asian survey respondents. To be sure that these data were giving a real account of the experience of such patients, the researchers carried out an experiment to test whether South Asian patients either report poorer care because they get lower quality care or receive similar care but rate it more negatively. A well-established way of doing this is to ask respondents to watch and rate standardised clinical scenarios or ‘vignettes’.
Videos of simulated GP-patient consultations were shown to two groups of people (Pakistani and White British) who were asked to rate the quality of the communication in each consultation on the five dimensions for consultations in the actual GP Patient Survey. Three key issues were built into the design of the experiment: the symptom the patient came to see the doctor about (there were four different ones); the quality of the communication (poor versus good); and the ethnic backgrounds of the ‘doctor’ and the ‘patient’ – either South Asian or White British.
The vignette exercise was conducted in English as it was not possible to produce equivalent vignettes in community languages. This approach was consistent with the fact that 99.8% of responses to the GP Patient Survey are in English.
Equal numbers of White British and Pakistani patients with slightly differing age and gender profiles took part in this experiment. Respondents from a Pakistani background rated communication in the simulated GP consultations significantly more positively than their White British counterparts. These differences were in the opposite direction to those seen in the national GP Patient Survey, where Pakistani respondents give significantly lower scores for communication than White British patients. What this suggests is that not only are there differences in the real-life GP consultation experiences of White British and South Asian patients but that these differences are even greater than previously reported via the GP Patient Survey. The researchers suggest that Pakistani patients experience genuinely worse GP-patient communication and that practices should be encouraged to take these factors into account when considering the issues involved in caring for a diverse patient population.