Patient-Perceived Quality in Primary Care

This report presents analyses of patients' own experiences in primary care based on the National Patient Survey.

Recent years have seen a growth in the interest in, and need for, measurement and open reporting of the degree of patient satisfaction. The national patient questionnaire, first conducted in 2009, is a clear example of this. The purpose of the national patient questionnaire is to bring out patients’ experience of healthcare as part of the work being done on the development and improvement of healthcare, as well as to support patients in choosing their healthcare provider. If the results are to be used as the basis for choices by individuals, and as support to the work being done on change, it is of great importance to clarify which factors affect patients’ own assessments of the healthcare they receive.

This study analyses the correlations between six different measurements of quality in primary care as perceived by patients – for example, involvement, continuity and accessibility – and 13 different properties of clinics and surgeries, including size, ownership and mix of listed individuals. A study was made of which individuals are listed by clinics in respect of average healthcare needs (ACG, Adjusted Clinical Groups) and socio-economic profile (CNI, Care Need Index). The study is based on clinics that are part of the healthcare choice systems in the Halland, Skåne and Västra Götaland regions, which make up around one third of all primary care clinics in Sweden. Information on perceived quality from primary care clinics was obtained from the national primary care patient questionnaire of autumn 2010. The covariance between quality as perceived by patients and the various measurements of the clinics’ properties were then studied using statistical analysis.


  • Patient-perceived quality was lower in major cities and among clinics where listed individuals show more severe socio-economic conditions – though higher in patients with greater average healthcare needs. 

The study shows that the geographical location of healthcare providers, and differences in who the clinics list, are of significance to the scores that providers receive in the national patient questionnaire. The average patient-perceived quality was lower in major city areas and among clinics where listed individuals show more severe socio-economic conditions. At the same time, patient-perceived quality was higher in clinics with a greater average healthcare need among listed individuals.

  • Private clinics generally received higher scores – though not when the results were corrected for socio-economic conditions and healthcare needs. 

Private clinics generally received higher scores than county council-run clinics in the national patient questionnaire. Once the results were corrected for socio-economic conditions and the healthcare needs of the listed patients, private clinics received better scores in one of the seven measurements, i.e. overall impression. Furthermore, individual private clinics received better scores for continuity of healthcare compared with both private healthcare chains and county council-run clinics. However, private clinics were situated to a greater degree in areas of good socio-economic conditions, which contributed to the higher uncorrected scores for which a listing was made. It appears, therefore, that aspects which healthcare providers themselves cannot fully control, or are not intended to control, have an effect on patient-perceived quality. This demonstrates the complexity of reporting differences in patient satisfaction between private and public sector clinics without taking underlying factors into account.

  • Clinics with a higher number of listed individuals had lower patient-perceived quality. 

Several findings from the present study underline the fact that properties of the clinics themselves are of great importance in patient-perceived quality. For example, clinics with a larger number of listed patients tend to have a lower level of patient-perceived quality.

  • Clinics with a large proportion of visits to doctors had a higher level of patient-perceived quality. 

The study shows that the proportional distribution between the number of visits to a doctor and the number of visits to other healthcare staff is connected to patient-perceived quality. On the other hand, no correlation was found between the total number of visits and patient satisfaction. There was a positive correlation between a high proportion of visits to a doctor and patient-perceived quality following a visit to the doctor.

At the same time, it is interesting to note that visits to nurses in five of the seven quality dimensions studied received higher scores than visits to doctors. However, the perceived quality following a visit to a nurse also had a positive correlation with a higher proportion of visits to a doctor. The reasons behind these correlations and circumstances are not obvious and merit more in-depth studies.


The results of the study make clear the importance of assessing the problems involved in the interpretation and use of patient questionnaires for the assessment of various clinics. It is evident that there are difficulties associated with measuring patient-perceived quality of healthcare using patient questionnaires. Assessments and comparisons must be done fairly by taking into account, for example, which individuals are listed at clinics, as both socio-economic conditions and estimated healthcare needs co-vary with patient-perceived quality. This shows that it is necessary to use information on the composition of the patients at clinics and to study how this relates to the geographical location of healthcare providers. A true correction for background factors is particularly relevant if reimbursement in primary care is based on the results of patient questionnaires. If not, there is an obvious risk that reimbursements will not help in the development of quality.

The form of ownership – private or public sector – co-varies in some respects with differences in patient satisfaction. This demonstrates the importance of continuously developing ways and methods of working, as well as learning from those that succeed in achieving good results. The results of the study also emphasise the importance of continually evaluating the terms and conditions used by the county councils and regions for new clinics and reimbursement systems so that all healthcare providers operate under equal conditions.

Patient-perceived quality is not the only target in primary care. However, information on, for example, clinical quality and medical results from the various clinics is not available to patients and citizens. It is not until patients also have access to fit for purpose information on medical quality that they will have the opportunity to balance the various quality aspects against one another. This balancing has not been examined in this study, but it is important. In addition to this, patients also have varied preferences in terms of primary care and may, for example, attach different levels of importance to properties such as good continuity or accessibility. By extension, this means that it is valuable for clinics to have differing properties so that the varying needs of the population can be better met. An important principle in the three regions is for the clinics to have a wide degree of freedom in decisions about the organisation of the work. For this reasons, listing is done by clinic, not by individual doctor. The proportion of variable reimbursement based on visits to the different professional categories is small in Halland and has been removed entirely in the Skåne and Västra Götaland regions. If visits to doctors can be complemented and replaced by visits to nurses and other professional groups – so-called substitution – then doctors can devote their time to patients with more serious problems, which will lead to an improved utilisation of resources generally. At the same time, the various professional groups, including doctors, will have better opportunities for development and specialisation. The results point to a positive correlation between the proportion of visits to a doctor and quality as perceived by the patient. In that case, there may be a problem replacing a visit to a doctor with another form of visit if, at the same time, patients are not reassured by showing them that such changes actually lead to an improvement in quality.

Quality as perceived by patients is a vital component in the management of healthcare and medical care, but healthcare has other targets, too. It is essential, therefore, that the terms under which clinics operate should facilitate the opportunities to balance the various targets of healthcare and medical care, such as quality and cost-control. In this context, developing control systems that put the premium on quality development may be an important instrument in balancing other targets. For example, the study shows that patient-perceived quality is, on average, high in small clinics with a high proportion of visits to doctors. At the same time, it could be the case that clinics with this emphasis have fewer opportunities to meet other targets, such as good productivity and financial balance, for example. This knowledge is additionally important when the results of various clinics are being compared and used as the basis for rewards or sanctions of various kinds.

In order to increase certainty in future analyses of this kind, it is important to expand the analysis to cover several regions and county councils, to improve the reply rate in the national patient questionnaire, to monitor developments over time, and also to be able to study the variation in patient satisfaction at patient level.


  • There are several factors that it is important to consider when comparing and evaluating the quality of clinics based on information gathered through patient questionnaires. 

An initial factor is that there are general difficulties associated with measuring patient-perceived quality in healthcare using patient questionnaires. Another factor is that assessments and comparisons must be true and correct and must take into account which individuals are listed by the clinics. A third factor is that potential conflicts between targets for patient-perceived quality and other targets must be taken into account, and that the overall terms and conditions for establishing clinics should facilitate the opportunities to balance the various targets.


  • Information on the people whom clinics list is an important prerequisite for producing true comparisons and designing control mechanisms that are fit for purpose. 

The results indicate that several different properties among clinics – including size, ownership, location and the mix of listed individuals – co-vary with patient-perceived quality in primary care. Such properties may be affected to varying degrees by the clinics themselves. The analyses in the report show that differences in structures and in the people whom the clinics list co-vary with the score received in patient questionnaire studies. Knowledge of the socio-economic conditions and healthcare needs of the listed individuals is, therefore, an important prerequisite in the appropriate interpretation of the results of patient questionnaires. It is essential to make active use of information that describes the patient composition of the healthcare clinics. Only once this information is used will it be possible for the questionnaires to truly support the development and improvement work being carried out by the responsible healthcare authorities and providers.

  • It is important to use and develop information that provides better opportunities for qualified assessment and monitoring of healthcare from a patient perspective 

It is of great importance to have access to information on cost, accessibility, medical quality and perceived patient quality for individual clinics in order to provide individuals with a good foundation on which to base their choice of healthcare provider and to be able to design measures that are fit for purpose and that can increase the overall quality and efficiency of healthcare. Only once the healthcare players, as part of their operational development, have collected information on meeting targets in the various areas of healthcare and medical care will it be possible to balance the targets against one another and thus promote them together.