Discussion
Principal findings
The results of this study identify a good satisfaction with the care
provided by the GPs and the medical centre. In general the patients are
very satisfied with all aspects of care provided but particularly
satisfied with data confidentiality. The least satisfied patients were
with aspects that had to do with managing to contact their GP on the
phone and the wating time when they had an appointment.
Strengths and limitations
The major strength of the study was the fact that it is the first time
such as study take place after the major reformation of the healthcare
system in Cyprus. We had a representative sample from the largest group
practice primary care centre of Cyprus and the results showed a very
good satisfaction. The management of the centre are keen to identify
rooms for improvement and the findings have already been taken into
consideration and actions have been initiated.
The tool needs to be updated as it is traditionally been filled by
patients with the help of a researcher at the GP practice. With the
current pandemic, patient visits have been decreased and close
interaction between people is strictly prohibited especially in medical
centres. We opted for an electronic dissemination and this may have
decreased our response rate. Our data are heavily skewed towards
beneficiaries with tertiary education background therefore there may be
some probability of bias in our findings. But this may also be a true
representation of the population as Cyprus has the second highest
tertiary education % in Europe. Also the questionnaire asks for patient
visits and with the advancement of IT, the current pandemic, the excess
demand for service and the limited time resources other forms of
consultation have been on the increase such as telephone and video
consultations.
The study identified a “methodological problem”, that of the large
ceiling effects, which is consistent with previous EUROPEP studies. In
agreement with other authors, we found a skewed distribution towards the
“excellent” option therefore a large celling effect and a very small
floor effect. The high ceiling effect is potentially an indication of
lower responsiveness of the questionnaire. It is worth to be noted that
these ceiling effects were not generally higher for the current study
compared to other studies. It is worth to be noted that the criteria
used to evaluate ceiling and floor effects vary a lot among different
studies.
Another limitation of the study is the generalizability of the findings.
Although the sample size was good enough to make accurate estimates, it
is a single centre study at the capital of Cyprus, Nicosia. Although the
practice serves beneficiaries from both urban and rural areas, the
universal electronic health record as it stands does not provide the
opportunity to extract data to understand the case mix of the
beneficiaries registered with the practice, therefore we cannot be sure
of the generalisability of the findings.
Interpretation within the context of the wider
literature
Patient satisfaction is not a clearly defined concept, although it is
identified as an important quality outcome indicator to measure success
of the services delivery system. We used an internationally validated
patient satisfaction tool to assess for the first time the satisfaction
of patients in primary care in Cyprus after the major healthcare
reformation of 2019. Our overall patient satisfaction is generally in
line with results from a study that was performed in 2010 in Cyprus
looking at diabetic and hypertensive patients. Overall our study
findings are in line with all other international findings that have
used the EUROPEP tool. We have seen that patients are particularly
satisfied with the safeguarding of confidentiality but usually the worst
satisfaction item is the waiting time before consultation with the GP.
The original work of the EUROPEP tool categorises primary care in five
distinct categories; availability and accessibility, information and
support, medical technical care, doctor–patient relationship and
organization of services. We have not been able to identify any scales
using the data we collected although internal reliability was very high.
This inability to identify the five distinct categories may reflect the
need for additional indicators based on single items or new refined
scales. To add to this this is something that many of the studies
looking at the EUROPEPR have identified.
Implications
It is evident that the Greek EUROPEP can be used as a quality assessment
and thus an improvement tool in Cyprus. This study has implications for
the managers of the medical centre as well as national and international
policy health leaders. Nowadays, the participation of the patients and
their contribution to the mapping out of health policy is essential.
Their engagement of patients in the assessment of the services and the
empowerment of patients in the promotion of the acknowledgment of
populations’ health needs is recommended. Managers of the medical centre
have already been informed of the study findings and they have already
addressed some of the issues such as getting more admin and IT support
for better contact between beneficiaries and GPs as well as better
appointment management to reduce the waiting times. Since the
cancellation of the electronic appointments due to COVID 19 the call
centre has been struggling to adequately respond to the pts needs.
Alternative solution that were implemented such as emails, live chat and
texting seem to work.
The HIO should use the findings of this study as a steppingstone to
implement a nationwide study to assess the patient satisfaction in the
entirety of Primary Care so that it can be evolved. As in other
countries with similar national health systems, Primary Care acts as the
gatekeeper of the system. Differences in the satisfaction of the
beneficiaries can be a potential concern for differences in the quality
of care provided therefore, health inequalities. Such studies should be
performed in an annual basis to supplement targeted quality improvement
interventions, with the results being publicly to ensure transparency
and foster patient empowerment. Besides the quality improvement of the
Primary care of the country, the use of the tool in a national study
would provide baseline data for international comparisons.
In addition to the quality assessment of the Primary care and on our
survey results the HIO should focus their efforts on health literacy for
beneficiaries to get a good understanding of the GP’s role in the new
NHS. Furthermore, HIO in collaboration with Cyprus Medical and Patients
Association need to implement professional development courses in order
to improve adherence to clinical guidelines/evidence-based medicine,
performance of clinical auditing, empathy, compassion, as well as
communication skills which will lead to improved patients satisfaction
and NHS healthcare quality with cost-savings at the same time.