Do sexual health staff know what patients want from services?

INTRODUCTION

There are probably four paradigms in contemporary affluent country health care: (1) cost-effectiveness, (2) evidence-based medicine, (3) health for all and (4) patient provider partnership.

To achieve cost-effectiveness, the application of managerial approaches first applied in industry has been recommended for over 20 years. ¹ The British National Health Service currently favours Lean Management. ^2,3 In Lean Management a complex process is broken down into its component parts and then analysed to ensure that each step adds value to the final outcome. If a step adds no value it is seen as wasteful, reducing the efficiency of the process, and can be eliminated. If the principles of Lean Management are applied, every step in a process contributes towards the final objective.

To apply evidence-based medicine, health workers need to know which objective should be achieved. Professional and statutory bodies demand that these objectives are reached in partnership between patients and providers. ⁴ Unless the objectives of a health-care episode are agreed between patient and provider, adherence to the four paradigms would occur more by chance than by design. This is not only the case of individual care episodes but is likely to also apply to systems of service delivery.

Unless providers know what patients (as a group) value, meeting their expectations and objectives may in part be coincidental. We need to know whether we are accurate in anticipating their need.

This paper presents our own assessment of our ability to predict the priorities of our patients.

METHODS

To determine our own ability to predict the priorities of patients when attending a sexual health clinic, we conducted two self-administered parallel surveys (one on patients and one on staff) using the same survey tool.

These surveys were carried out in the Department of Reproductive and Sexual Health (RASH) in Enfield, in February 2009. This service offers a comprehensive range of sexual health-care services through a single access point. All clinical staff had dual training in genitourinary (GU) medicine and sexual and reproductive health (previously called family planning). The majority of staff (90% nurses and 75% doctors) saw patients accessing the integrated sexual health clinic (where both GU medicine and contraception needs are met).

In the patient survey, we collected information from 252 patients about their expressed needs. The methods and results are reported elsewhere. ⁵ In brief, to prioritize which aspects of health care were most valued, patients were asked to allocate 10 stickers between 12 attributes of sexual health care. Patients could give more stickers to attributes of health care that they valued highly. The 12 attributes covered technical, interpersonal and organizational/managerial aspects of care (see Table 1).

We calculated the percentage of stickers allocated to an individual attribute.

In the second survey, members of sexual health-care staff – doctors, nurses and administrative staff – were asked to predict the distribution of stickers made by the participating patients as a group, i.e. to guess which attributes of sexual health-care patients most valued.

Staff were also asked to report whether they were a doctor, nurse or administrative member of staff and whether they had any direct or indirect contact with the patient (telephone, face-to-face or neither), but no further provider identifying information was recorded to maintain anonymity.

To determine which provider group's evaluation was closest to the priorities expressed by patients, we focused on accurately predicting the patients' top three priorities.

The questionnaire tool had previously been piloted and underwent validation for understanding through face-to-face interviews with patients. It was felt that the questionnaire was clear and easily understood. The local Research Ethics Committee deemed the project to be a service survey and not in need of ethical approval.

RESULTS

The results of the original patient survey, ⁵ which questioned 252 patients attending an integrated sexual health clinic, found that patients' top three priorities were confidentiality followed by speed of service and then rapid test results. The staff questionnaire showed an 87.5% response rate with 28 completed forms out of the 32 distributed. In all, 39.3% of respondents were nurses, 32.1% administrative staff and 28.6% doctors. All the doctors and nurses had face-to-face contact with patients and 44% administrative staff (see Table 2).

When all members of staff were analysed together, they were found to correctly predict the top three patients' priorities (confidentiality is more important than speed of service, which was more important than rapid test results) in the right order (see Table 3).

However, there was marked variation when comparing the opinions of different staff groups. Doctors felt that patients were most likely to value seeing someone who was friendly and listened to them (20.6% of sticker allocation) whereas nurses scored this seventh in the list of 12 (4.8%). Also, doctors felt that seeing a clinical expert was the third most valued aspect of care (10%), but this was thought by nurses to be much less highly valued, who placed it seventh equal (4.8%) and as found previously from the patient survey ninth in the list (6.26%).

Interestingly after their top priority of confidentiality (17%), administrative staff felt that patients would most value having a choice of whom they saw, be it a doctor or nurse and whether they were male or female (12.9%).

In order to measure who assessed patient priorities most accurately, we added up the differences between provider (doctor, nurse or administrative staff) and patient priorities. The smaller the number, the closer the assessment was to what patients had stated was their priorities. The results showed that nurses were closest (34.8) followed by administrative staff (38.8). Doctors were least accurate (58.2).

Nurses correctly identified three out of three of the patients' top priorities (although not in the same order), administrative staff identified two and doctors one.

DISCUSSION

When taken as a group, sexual health-care providers' views accurately reflected those of patients. However, no individual group of providers was able to accurately predict the three top priorities of our patients. Interestingly, doctors appeared to be least able to assess patients' priorities and nurses appeared to be most precise. Lack of knowledge or skills is unlikely to explain these results as this group of doctors have been working in integrated sexual health for more than three years and all have postgraduate qualifications in sexual health care. Furthermore, doctors as a group had very similar answers. Instead we suggest two possible explanations:

Firstly, doctors' training traditionally focuses on the disease or more recently on a problem-centred approach. ⁶ The patient presents with a collection of signs and symptoms, which must be solved to provide the treatment or answer to the medical conundrum. The traditional nurse training is perhaps more patient centred. ⁷ This may give nurses a greater appreciation of the needs of the patient.

Secondly (and probably more importantly), while receptionists will have brief contact with all patients, doctors and nurses working in sexual health have longer contact with a patient but only see a purposefully selected sample of the general sexual health patient population. In our integrated sexual health clinic, receptionists would help the patient to identify their primary reason for attendance (in our service patients can choose between four management options: quick sexually transmitted infection (STI) screen only, quick repeat contraception only, contraceptive procedure or anything else) and ask about any special needs (language, gender of health worker). Nurses see the majority of patients, including all who want an STI ‘check-up’ or have simple genital symptoms or request non-invasive contraception. Doctors, on the other hand, see a much smaller sample of patients with complex health issues and those requiring contraceptive procedures (intrauterine device or system, subdermal implant insertion). These patients are more likely to value medical expertise and would also want to see someone who listens and is friendly. They may not be so concerned about being managed quickly within the service and may be prepared to wait to see someone with the required level of clinical expertise. We believe that the sample selection and the mode and content of information collection determined the health workers' perception of patient priorities and the differences found between health worker groups.

There may be a place for future studies to survey the various management options separately (e.g. STI check-up patients or those attending for contraceptive procedures) to determine which group of patients wants what.

This does not exclude other explanations; for example, although the original patient survey showed no differences between different sociodemographic groups (age, sex and ethnicity), we did not collect this information about providers. We therefore cannot exclude that such factors may account for differences or similarities rather than different groups of health-care provider. Also, employment history such as the length of time in service or duration of employment in the integrated clinic was not determined and could affect the results.

We acknowledge that the study is small and relates only to our own department, but we suspect that we are not unique. This would have important implications for service design, departmental policy setting and also the development of guidelines. If doctors are not best at predicting patient priorities for the majority of patients (and in this study nurses and administrative staff appear to be better), perhaps during policy, guideline and service development we have to ensure that the full knowledge of the multidisciplinary team is used.

CONCLUSION

Given the importance that is given to the four paradigms of health care, we were surprised that we could not find any publications addressing the question: ‘Do we know what patients want?’.

At least in our own unit doctors appeared to be the least able to predict patient priorities for the patient group as a whole. One of the immediate outcomes of this study was for us to make more effort to accurately assess priorities in partnership with a patient during an individual care episode and to review our ‘doctor developed nurse/administrative staff approved’ clinic guidelines.