This study conducted a secondary analysis of repeated cross-sectional national survey data to examine factors associated with patient experience in Scottish general practice. The analysis aimed to quantify the relative contributions of practice size, socioeconomic deprivation, and rurality to practice-level patient satisfaction and to describe temporal trends across survey waves from 2009–2010 to 2021–2022.
The analysis used data from the Scottish Health and Care Experience (HACE) survey collected biennially between 2009–2010 and 2021–2022, linked to publicly available national datasets for practice characteristics. After exclusions, data from 632 general medical practices were analysed, representing 63% of the 1,008 practices that originally participated in the survey programme. Practices were excluded for reasons including potential closures or mergers, changes in urban–rural classification, or missing practice population size data.
Response rates across survey waves varied between 16% and 38%. The highest response rates were observed in the most remote and in the least deprived areas. The dataset for analysis therefore reflects variation in response by geography and deprivation, and the authors reported exclusions that reduced the analysed practice sample from the original participating practices for specific administrative or data-quality reasons.
Primary outcomes were practice-level percentage positive responses to seven HACE survey items. These items addressed dimensions of patient-centred care and continuity of care and were derived from questions asking respondents to indicate their level of agreement. For each practice, the percentage of positive responses for each item was calculated and used as the dependent variable in analyses of associations with practice and area characteristics.
The investigators used regression models alongside a relative importance method to partition explained variance among predictors. Predictors included an eightfold urban–rural classification, area deprivation quintile, and practice size quintile. The relative importance analysis quantified the share of explained variance attributable to each domain (rurality, deprivation, practice population) for individual survey items. Sensitivity analyses excluded practices with large changes in practice size and assessed potential impacts of minor wording changes in survey items.
Satisfaction levels captured by most HACE questions were broadly stable across survey waves up to and including 2019–2020. The 2021–2022 survey wave showed a marked decline in reported satisfaction across most items compared with prior waves. The timing and magnitude of the decline are reported relative to earlier biennial waves in the HACE series.
Across survey waves, consistent patterns emerged:
Participants in more rural areas reported higher satisfaction levels relative to urban counterparts.
Patients registered with smaller practices consistently reported higher satisfaction over time.
Patients registered with practices in more affluent areas expressed moderately higher satisfaction in most domains.
Relative importance analysis emphasised the dominant role of socioeconomic status and practice population in explaining variation in satisfaction: area deprivation accounted for as much as 71% of the explained variance for individual items, and practice population accounted for as much as 86% for individual items. By contrast, rurality contributed a smaller share of explained variance, in the range of 5% to 18% depending on the item.
Sensitivity analyses that excluded practices with large changes in practice size and that accounted for minor changes in survey wording confirmed the main findings. These checks supported the robustness of the observed associations between satisfaction and the predictors of deprivation, practice size and rurality, and of the temporal decline observed in the most recent survey wave.
The study documents a marked decline in measured patient satisfaction after 2019–2020 in Scotland. Over the survey period, higher satisfaction was consistently reported by patients in more rural areas, by those registered with smaller practices, and by patients in more affluent areas. In the most recent survey wave, socioeconomic status (area deprivation) and practice size were the strongest correlates of practice-level patient satisfaction across most items. The authors note that further work is needed to clarify the mechanisms driving these associations and to understand the causes of the post-2019–2020 decline. The study provides a basis for targeted investigation and for consideration of how practice configuration and area-level socioeconomic factors relate to patient experience measures.
Details on limitations reported in the source include the reduced analysed sample of practices (632 of 1,008) due to exclusions for administrative or data-quality reasons, and variation in response rates by geography and deprivation. The source also reports that sensitivity analyses addressed some potential biases (practice size changes and minor question wording changes), but additional limits inherent in secondary analysis of repeated cross-sectional survey data remain and were noted as a reason for further research to clarify mechanisms.