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.