Journal of Public Health Medicine
236-249
The measurement of patient satisfaction
Roy A. Carr-Hill
Summary
Many applied health service researchers launch into patient
satisfaction surveys without realizing the complexity of the
task. This paper identifies the difficulties involved in execut-
ing patient satisfaction surveys. The recent revival of interest
in 'satisfaction' and disagreements over the meaningf ulness
of a unitary concept itself are outlined, and the various
perspectives and definitions of the components of satisfac-
tion are explored. The difficulties of developing a compre-
hensive conceptual model are considered, and the issues
involved in designing patient satisfaction surveys - and the
disasters that occur when these issues are ignored - are then
set out. The potential cost-effectiveness of qualitative
techniques is discussed, and the paper concludes by dis-
cussing how health care management systems could more
effectively absorb the findings of patient satisfaction sur-
veys.
I Background
This paper is concerned with the problem of measuring
patient satisfaction. The main focus is on the method-
ology of patient satisfaction surveys, with a subsidiary
concern being the technical problems of carrying out
such surveys. First, however, the purpose of measure-
ment must be clarified and the concept itself has to be
defined.
I.I Why measure satisfaction?
Superficially, the question itself is strange, for, given
that the fundamental raison d'etre of the doctor is to
serve the needs and wishes of the patient and work
towards the good of the patient (for a contrary view, see
Ref. 1), an understanding of patients' concerns and
interests is central. One would have thought that
assessing satisfaction would be a natural sequel. But less
than a decade ago Ware el al? felt obliged to defend
their 'strange' preoccupation with patient satisfaction:
'even the most conservative critique of the literature
would conclude that there is some evidence for the
usefulness of the satisfaction concept in predicting what
people do at a very general level (e.g. total consumption
of health and medical care resources) and at the specific
level (e.g. appointment keeping)'.2
Vol. 14, No. 3. pp.
Printed in Great Britain
Yet satisfaction with care had already been established
as an important influence determining whether a person
seeks medical advice, complies with treatment and
maintains a continuing relationship with a practitioner.3
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Direct associations had also been found with thera-
peutic outcomes and health status, although it is not yet
established whether this is due to the therapeutic value
of the doctor-patient relationship or to social aspects of
healing; for example, Kincey et al.* showed that satisfac-
tion with information is significantly associated with
subsequent compliance.
There are also political reasons for the growing
interest in the patient's views. In principle, if the
perspective of the patient were to be given more
importance, this would help to counteract the medical
hegemony.5 The dominant political theme in the United
Kingdom, however, has been the emphasis placed on
consumer sovereignty; health care provision is expected
to be shaped by (potential) patients' demands and
preferences.6 In this mode, consumer satisfaction would
be considered as an outcome of the health care process.
However, to be used in this mode, measured con-
sumer satisfaction has to be sensitive to variations in the
quality of the service provided. This criterion would
exclude the routine use of in-patient questionnaires, as
respondents to a standard questionnaire in the United
Kingdom are typically 85-90 per cent satisfied.7 Not
only is there little variation-(and such levels are
obviously of limited use to a health services manager
other than for public relations purposes)-but he or she
needs to know what is wrong, not what is right. More
generally, one must doubt the utility of a construct
which commands such levels of assent and is undifferen-
tiated through the population. Indeed, even when
patients report high levels of satisfaction, Carstairs
Centre for Health Economics, University of York, York YO1 5DD.
ROY A. CARR-HILL, Senior Research Fellow in Medical Statistics,
This paper was commissioned for the Faculty of Public Health Medicine
Journal of Public Health Medicine.
© Oxford University Press 1992
 THE MEASUREMENT OF PATIENT SATISFACTION
showed how the volume of comment was a more
sensitive indicator.8
However, although relatively high levels of satisfac-
tion are usually reported, in a survey in the mid-1980s9
only 36 per cent (n=1500) thought that overall the
National Health Service (NHS) was 'extremely good' or
'very good'. The same survey showed that 26 per cent of
the sample had used one or more forms of alternative
medicine, suggesting dissatisfaction with some aspect of
conventional medical care. A contemporary survey10
compared the public attitudes towards the NHS with
their attitudes to private medical care and found marked
dissatisfaction with the former. Indeed, this has been
seen as one of the reasons for the growth of private
health care insurance. It is important to recognize the
potential political role of results of satisfaction surveys;
for, as we shall see, the scope for manipulating the
design-and therefore the findings - of satisfaction
surveys is legion.
1.2 Is there a concept of satisfaction?
What is satisfaction? How is it defined? What does it
mean to different people? What is the referent about
which the patient is meant to be satisfied?
Human satisfaction is a complex concept that is
related to a number of factors including life style, past
experiences, future expectations and the values of both
individual and society. The issue has been studied
extensively by the Survey Research Centre at Michigan
(see, e.g. Ref. 11). Studies from this centre divided
people's satisfaction into different life 'domains'
(including own health but not health care received) and
argued that each of those domains has a conceptual
coherence. Regardless of one's judgement of this overall
approach, most would agree that satisfaction with
health care in general is predominantly a derived
concept. For those who do not see themselves as needing
health care, discussion of their satisfaction rating with
health care is, therefore, problematic.
Because satisfaction is a derived concept, any investi-
gation must search for sources of dissatisfaction. In
addition to different preferences about the hotel aspects
of care, a doctor who, by certain technical standards,
practises good-quality medicine may have a poor
satisfaction rating because a number of his patients do
not share his views about what constitutes good-quality
medicine. Given that the most frequent source of
dissatisfaction is the communication of information
about the condition and about the appropriate treat-
ment, these 'clinical' issues and the relative expertise,
knowledge and therefore power of doctor and patient
have to be central to any investigation of (dis-)satisfac-
tion.
Further, because the sources of dissatisfaction can
237
vary widely, satisfaction is likely to be defined very
differently by different people and by the same person at
different times.12 This interpersonal and over-time var-
iability casts doubt on the value of attempting to define
a unitary concept of satisfaction: in addition, patients'
expectations will vary according to the presumed suc-
cess of the intervention and to their experience of
medical care. Indeed, an understanding of how experi-
ence affects satisfaction helps to explain why older
patients who can remember the pre-NHS days are more
satisfied with the NHS and the services it provides than
those who have never known anything but the NHS.13
However, there are few other consistent relationships
between measured satisfaction and any socio-demo-
graphic characteristics. This is surprising. First, differ-
ent groups may have different response tendencies; for
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instance, older patients may be more mellow, and more
educated patients may apply higher standards in their
evaluations. Second, different groups may be treated
differently in the process of care: older patients may be
treated more gently, and doctors may communicate
more with middle-class patients.14 Yet, Fox and
Storms15 felt obliged to summarize the situation as
follows:
'The literature on satisfaction with health care presents
contradictory findings about sociodemographic vari-
ables. . . . The situation has grown so chaotic that some
writers dismiss [sociodemographic] variables as reliable
predictions of satisfaction.' (Ref. 15, p. 557.)
In the meta-analysis of Hall and Dornant,16 relations
were extremely small (with a maximum correlation
coefficient of r = 0-14) even when statistically significant.
Moreover, even established correlates of satisfaction
such as patient's health status,17 the physician's commu-
nicative behaviour and the physician's technical com-
petence18 do not yield high correlations.*
At the same time, many current conceptualizations of
the variable 'satisfaction' are limited to operationalizing
the reaction to the medical encounter rather than an
active involvement in the therapeutic process. Speedling
and Rose5 argued for a move to a more proactive
concept of patient participation, but they limited their
suggestions to obtaining patient preferences as an input
to clinical decisions. This, however, restricts the patient
to 'participating' within a very rigid 'QALY' (Quality
Adjusted Life Year) type framework.20 Instead, one
might want to envisage participation in terms of being
involved in deciding the kinds of services that are
provided.
Thus when health care is provided at least in part as a
* One classic study" examined correlates of satisfaction when its mean
was 14-78 on a 0-1S scale. This is nonsense. One of the reasons for the
low correlates of satisfaction is the small range of variability.
238 JOURNAL OF PUBLIC HEALTH MEDICINE
public service, clinical effectiveness and economic effi-
ciency cannot be the sole criteria; the health care has to
be socially acceptable. For example, the growing resis-
tance to animal testing of pharmaceuticals is posing
non-financial and non-medical constraints on what
drugs can be used. Consumer satisfaction is then an
outcome of the health care system. It is trite to say that
satisfaction has several different meanings; it highlights,
however, the importance of distinguishing between the
phenomenon - however defined - and the measurement.
1.3 An index of (patient) satisfaction
Work in other fields has shown the complexity of a
satisfaction index. Researchers at the Survey Research
Centre of the University of Wisconsin have tried for
nearly 20 years to persuade their readers that a global
index of satisfaction can be derived from responses to
questionnaires to measure overall well-being,21 but few
were or are convinced.22
In the health care context, satisfaction is also often
thought of as a unitary concept, although perhaps
dependent on several others. Factor analytic studies of
instruments have suggested there might be a common
factor, but most researchers217 argue that various
aspects or dimensions are distinct. For example, the
Health Policy Advisory Unit (HPAU) claimed that
'The technique of factor analysis has demonstrated that
patient satisfaction is chiefly determined by six dimen-
sions (medical care and information, food and physical
facilities, non-tangible environment, quantity of food,
nursing care, visiting arrangements), and results are
analysed in relation to these underlying dimensions.'
(Ref. 23, p. 7.)
Whether or not these are the 'underlying' dimensions,
the important issue is whether they can be combined
into one overall index of satisfaction.
Assuming that distinct dimensions of satisfaction can
be defined, the researcher is now forced to take several
backward steps. For, to produce an overall satisfaction
score, the scores on the different dimensions have to be
weighted. Unless the researcher is prepared to make
arbitrary assignments of weights, then weights have to
be determined in a prior separate exercise.
The fundamental issue, however, is a question not of
the appropriateness of factor analysis or other statistical
packages, but of how people's views about the impor-
tance of the different dimensions are to be taken into
account. There are two possible approaches to estimat-
ing the weights: direct and indirect. In the direct method
people are asked to assign a weight or value directly to
each dimension. Sutherland et al.2* argued that raters
tend, in this method, to assign equal unitary weights to
each dimension. The alternative approach is to find a
way of eliciting weights from judgements made by
respondents to a range of questions, e.g. scenarios or
vignettes, combining the dimensions. Froberg and
Kane25 argued that the latter approach is suspect. The
statistical reduction to a single index presumes that
there is an underlying unity to 'satisfaction', for which
there is very little evidence.
II Defining the scope
These disagreements over the purpose of measuring
satisfaction and over the definition highlight the impor-
tance of specifying the scope of the various concepts of
patient satisfaction and, subsidiarily, the scope of this
paper.
The terms 'customer' and 'consumer' originate in the
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private rather than the public sector. The characteristics
associated with consumers in the private sector do not
necessarily 'translate across' in an unproblematic way.
First, it is important to remember that in addition to
patients (people undergoing medical treatment), rela-
tives, departments within the NHS (the internal cus-
tomer) and, where health education and promotion is
concerned, the whole population, are also users. A
sensible division is between current users and potential
users and then, within each group, those actually
concerned, their carers and professional groups. Hence
the typology laid out in Fig. 1.
II.I The aware and informed consumer
The accountant's (sorry, economist's) dream is of the
potential patient (consumer) as the perfect market
player. Floating with the tide, the National Consumer
Council has suggested seven principles which might help
to redress the imbalance of power between those who
(1) Current users
(a) Patients of various services
(b) Relatives
(c) Other professional groups (e.g. social workers, voluntary
organizations)
(d) Other NHS departments (internal customers)
(2) Potential users
(e) Relevant population categories (children, elderly,
handicapped, (ethnic) minorities)
(f) Consumer organizations
(g) Interested and informed people (e.g. health authority
members. Community Health Councils, researchers)
FIGURE 1 A typology of consumers.
 THE MEASUREMENT OF PATIENT SATISFACTION 239

Principle Statement of principle Applicability of these principles to health care

Access Can consumers obtain goods or use the service at all Cannot be translated into a right, as beneficiaries are not
necessarily same as contributors

Choice Consumer choice will work where there is effective Cannot be main determinant, as provision of public service
competition and where the balance in the market-place is involves redistribution
fair between supplier and customer

Information Consumers cannot make accurate judgements about what Cannot work fully because of technical issues involved
serves their best interests unless they have the information
they need to do so; that information needs to be accurate
and to be expressed in ways the individual can cope with

Redress The whole process of effective choice based on fair There is an obvious difficulty of getting redress if
competition is vitiated unless consumers can get redress in something goes wrong
the event that they do not get what they believed they

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were paying for

Safety Consumers can buy with confidence only if they expect Not all risks can be determined in advance
that the products they buy will not subject them to risks
they cannot foresee

Value for The value consumers get in terms of satisfaction for the In public service, patients are not directly paying for
money resources they spend treatment

Equity Consumers should not be arbitrarily discriminated against This is directly applicable if we are all seen as consumers
for reasons which are unrelated to their characteristics as
consumers

FIGURE 2 National Consumer Council 26 guidelines and their applicability in health care.

provide services and those who receive them.26 These are
set out in Fig. 2, together with an assessment of their
applicability to the health care situation.
It is clear that the basic principles of consumer rights
cannot easily be applied in the health care context.27 The
obvious non-starter is the principle of redress. But there
are problems in applying the other principles. For
example, in a tax-based system of health provision,
those who pay for health care are not necessarily the
same as those who benefit (and the same is true for any
other public service). Indeed, as the provision of public
services usually involves redistributing costs and bene-
fits within society, individual consumer choice cannot
be the sole driving force that dictates who benefits and
who pays. The principle of consumer access cannot
therefore be translated into an automatic right for the
consumer; equally, the principle of value for money is
vitiated in a publiclyfinancedservice.
The applicability of the principles of choice and
information seems doubtful: patients, in vivo, are in a
less powerful position and clearly are not able to judge
technical quality. On the other hand, several studies'8'28
show how satisfaction ratings correlate positively with
expert-developed indices of technical quality. This may
be because medical staff delivering good technical care
also take pride in their work, and this leads to raised
morale, which affects satisfaction levels.
Whether or not the same applies to 'expert' judge-
ments of risk and hence safety (the fifth principle) is
another matter. In the health state valuation literature
researchers using the standard gamble approach are
encountering relatively high levels of 'inconsistent'
responses.29 In fact, the only principle which seems to be
directly transferable - equity - is, sadly, the most
Utopian, and is, in any case, a system rather than an
individual consideration!
Of course, principles developed in an attempt to
control the savagery of the market of things in the
private sector are not ipso facto inapplicable to regulat-
ing relations of service in the public sector. Indeed, the
fundamental issues are very similar, as Potter con-
cluded:
'Consumerism can help authorities to advance from
considering individual members of their public as
passive clients or recipients of services - who get what
they are given for which they must be thankful - to
thinking of them as customers with legitimaterightsand
240 JOURNAL OF PUBLIC HEALTH MEDICINE
preferences as well as responsibilities. But it will rarely
be enough to turn members of the public into partners,
actively involved in shaping public services . . . Consu-
merism is fine as far as it goes, but it does not go far
enough to affect a radical shift in the distribution of
power.'(Ref. 27, p. 157.)
II.2 Individual health care versus collective con-
sumption
Part of the problem arises from the different meanings
of the words 'customer' and 'consumer'. The word
'customer' has an individual connotation, as in 'the
customer comes first'. 'Consumer', on the other hand,
has the connotation of a social category in that it usually
refers to the individual as being part of a group of users,
as in 'a consumer organization'. Correspondingly, the
term 'consumer view' can either refer to an aggregate of
views (as in a market research survey), or to a collective
view (as in a joint decision). The latter (a collective
decision) is more usually associated with participation
in decision-making, that is, the involvement of service
users in making decisions about the provision of
services.
These two meanings of the term 'consumer' are
highlighted in dissatisfaction expressed by some critics
of patient satisfaction surveys (which are a form of
market research). Scrivens30 described this view when
she wrote:
'The "supermarket model" of health care denies
patients and consumers the right to consultation about
investment, to what should be "on the shelves" and does
not encourage customers to seek redress if the products
are faulty.'(Ref. 30, p. 132.)
A position arrived at collectively may not be the same as
the aggregate of views of individuals in that collectivity.
All three aspects, that of the individual customers,
consumer views and collective participation, are rele-
vant to the NHS. First, there is a pure customer
orientation, as in 'the individual customer comes first'
or 'individuals must be treated as such and not as
numbers of machines'. At its most basic, the patient's
needs and wishes should receive attention. Second, the
market research approach is aimed at obtaining the
views of the majority of users about aspects of service
provision; and, it is hoped, about the levels and sources
of dissatisfaction. Third, customers/consumers as a
group, or collectively, should receive sufficient know-
ledge and power to enable them to take part with
providers in the process of making decisions the out-
come of which will affect them.
This paper is obviously concerned mainly with the
second aspect, although the other two aspects should
not be ignored.
II.3 Aspects of satisfaction
The HPAU24 claimed that there are six underlying
dimensions to patient satisfaction, viz., medical care
and information, food and physical facilities, non-
tangible environment, quantity of food, nursing care
and visiting arrangements. Of course, they were analys-
ing the dimensions of satisfaction with in-patient care,
not all of which are applicable to other types of care.
Williams and Calnan31 argued that there are general and
specific aspect dimensions across a broad range of
health care related to the issues of access and informa-
tion; and aspects specific to each area of health care. But
their analysis is weak - with no explicit testing of the
(dis-)similarity of effects. Hall and Dornan in their
meta-analysis of 221 - mostly US - studies32 categorized
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the aspects covered as follows: humaneness (65 per
cent), informativeness (50 per cent), overall quality (45
per cent), overall (44 per cent), technical competence (43
per cent), bureaucratic procedures (28 per cent), access
or availability (27 per cent), cost (18 per cent), physical
facilities (16 per cent), continuity (6 per cent), outcome
(4 per cent), handling of non-medical problems (3 per
cent). The rationale for distinguishing humaneness from
the other aspects - which can each be more or less
humane - and from overall quality is unclear.
It is for these kinds of reasons that, despite the
difficulties of applying the seven consumer principles to
the health care 'market', they do provide a coherent
framework for discussing the various aspects of satisfac-
tion which should be covered in any instrument. In the
York data base of consumer feedback surveys in the
United Kingdom, only access, information and overall
quality of the process are addressed consistently.33
Operationally, therefore, not only are satisfaction
surveys inappropriate for addressing the issue of equity;
in practice, they do not address problems of choice,
redress or safety, and on a more detailed level, the lack
of attention to psycho-social problems, and especially to
outcome, is outstanding.
The recent moves in the United Kingdom to propos-
ing a standardized questionnaire34-35 do not appear to
have been based on any systematic consideration of
these principles, nor, indeed, on any other conceptual
framework. If a general, rather than context-specific
questionnaire is to be devised, it ought to be able to
provide a coherent, theoretically based account of why
it is appropriate to treat satisfaction as a unitary
concept; at the very least there has to be a clear
statement of what are the essential aspects of satisfac-
tion. This is notably absent from the CASPE (Clinical
Accountability, Service Planning and Evaluation)34 and
NAC (National Audit Commission)35 efforts: the
HPAU24 approach is, of course, much more thorough,
 THE MEASUREMENT OF PATIENT SATISFACTION
but even their rather long questionnaire hardly touches
on outcome, redress or safety.
Ill The importance of a conceptual model
Assuming that it is agreed that satisfaction is multidi-
mensional, the next issue is how should each of the
separate dimensions of satisfactions - for example,
those enumerated in Section II.3 - be assessed? The
naive approach 'how satisfied were you with the (nurses/
doctors, etc.)' employed by CASPE34 and the Newcastle
Health Services Research Unit,36 among others, will not
do. This is partly for practical reasons - far too many
claim they are 'satisfied' - and partly because the extent
of dissatisfaction does not tell us what needs to be
changed. For the respondents' expressed satisfaction is
a relative judgement: a comparison between perceived
health status and aspiration. The proposition has been
elevated to the status of a 'theory' - the multiple
discrepancies theory37 - which is discussed briefly below.
The basic point is that, to assess expressed satisfaction
- in terms of reacting to it - it is insufficient to measure
just the level of satisfaction (the extent to which
aspirations are met given self-perceived status); both the
levels of aspiration and self-perceived status have to be
measured, for the former might be unrealistic given the
resources that are available, and the latter may, for some
people, be wildly different from their actual or 'objec-
tive' status.
In practice, the latter is unlikely in the context of a
satisfaction questionnaire. However, the requirement to
assess people's expectation is complex, for expectations
depend upon people's images of health, what is usually
expected of the health care system, and probably their
own experience. For example, Calnan38 suggested that
any investigation of lay evaluation of health care should
be carried out within a conceptual framework including:
(1) the goals of those seeking health care in each
specific instance;
(2) the level of experience of use of health care;
(3) the socio-political values upon which the particu-
lar health care system is based; and
(4) the images of health held by the lay population.
Such a model, although conceptually comprehensive,
poses considerable (impossible?) demands upon a ques-
tionnaire. For example, Williams and Calnan,31 claim-
ing to follow this model, included no questions on items
(3) and (4)! Moreover, the first item is not unproblema-
tic. First, no clues are given as to how to pose questions
on goals; second, the extent to which people have clearly
defined goals will depend on their prior knowledge and
possibility for independent action. This set of issues is
the subject of the remainder of this section.
241
TII.l The role of expectations
Stimson and Webb39 suggested that satisfaction is
related to perception of the outcome of care and the
extent to which it meets their expectations (see also
Locker and Dent12). Larsen and Rootman3 tested the
hypothesis that satisfaction with medical care is
influenced by the degree to which a doctor's role
performance corresponds to the patient's expectations.
They found a strong association between satisfaction
and a 'physician conformity index' which remained
statistically significant after controlling for socio-demo-
graphic factors and frequency of contact.
Friedson40 drew a distinction between ideal and
practical expectations, with the former being defined as
the preferred outcome given the patient's evaluation of
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their problem and their goals when seeking medical
care, and the latter being the anticipated outcome based
on the individual's own experiences, the reported ex-
periences of others, or knowledge from other sources.
The patient may express satisfaction because their
practical expectations were met, although the care they
receive does not meet all their goals (consumer-defined
need). In contrast, Fitzpatrick and Hopkins'" showed
how any tentative expectations were raised in the light of
experience of attendance at the clinic.
These apparently contradictory results may be recon-
ciled by postulating that negative experiences may be
easier to remember (they are more available in
memory).42 Therefore the longer the temporal frame-
work being evaluated, the more negative experiences are
recalled. Alternatively, patients may have a positive bias
when rating 'my care' to reduce cognitive dissonance.43
III.2 The multiple discrepancy theory
Michalos37'44 argued that the perceived achievement-
aspiration gap is the single most important contributory
factor to reported satisfaction across all domains of life.
However, he made no attempt to compare that model
against one which assumes that the single most impor-
tant contributory factor is the perceived current status
of the self in the domain of interest. Measured achieve-
ment-aspiration gaps in the Michalos approach may
well be rationalizations rather than causes of satisfac-
tion ratings.
Indeed, most of these analyses have failed to partial
out effects which could be attributable to a simple
relation between achievement and satisfaction; one of
the few studies which reports both the relation between
perceived achievement and satisfaction and between the
achievement-aspiration gap and satisfaction45 found a
stronger relationship overall between the former pair.
Moreover, the calculation of'gaps' on a scale with lower
and upward bounds automatically introduces an inverse
242 JOURNAL OF PUBLIC HEALTH MEDICINE
Relevant data - Perceived current Satisfaction
retrieved from status
semantic memory
Momentary relatively
'conscious' comparisons
(context-determined)
FIGURE 3 Current health status and satisfaction.
relation between the score on the first variable and the
gaps.46
Wright47 carried out a detailed study of the interrela-
tionships between self-rated achievements, self-rated
aspiration and self-rated satisfaction. He found that the
results contradicted the multiple discrepancies theory in
its present form. Satisfaction was not a function of the
calculated gaps between perceived current health status
and comparisons levels (e.g. aspirations). Instead,
Wright proposed an alternative model (Fig. 3). In this
model, it is crucial to ask about perceived current status,
as this is the main determinant of satisfaction.
III.3 Autonomy, control and satisfaction
Finally, despite the introduction of goals (expectations,
aspirations), the 'model' remains mechanical: patients
arrive with goals; doctors do something (or not); the
'satisometer' registers the 'result'. The reality is surely
different; whatever satisfaction 'really' means, it should
reflect, at least in part, the relationship between doctor
and patient. That relationship, structurally, is charac-
terized by differences in expertise, knowledge and
therefore potentially power; the extent to which patients
perceive themselves to be powerless will influence the
way in which they frame their expectations. Crudely, in
situations where patients have, or perceive themselves to
have, more control, they are more likely to pursue their
own goals; where patients see themselves as powerless,
then expectations will be redefined to match the prob-
able outcome.
Goals (expectations, aspirations) cannot, therefore,
be measured in a vacuum; they have to be situated in the
context of the structural relationship between the
patient and health care agents. These additional com-
plexities mean that those who set out to 'measure
satisfaction' are probably on a hopeless quest; for this
reason, the remainder of this paper, which is concerned
with methodological and practical issues, is confined to
the measurement of aspects of (reactive) patient satis-
faction.
IV Designing surveys to measure
(aspects of) satisfaction
The meta-analysis of 221 studies32'48 mostly in the
United States showed that the vast majority of samples
(82 per cent) were drawn from individuals known to
have received care from a particular site or system. Only
a small fraction of studies (14 per cent) included
experimental manipulation of factors supposed to be
contributing to satisfaction.
Hall and Dornan48 argued that the essential concep-
tual features of satisfaction instruments are directness,
specificity, type of care and dimensionality. Directness
refers to whether the patient is asked to give a satisfac-
tion rating or whether the researcher infers satisfaction
levels from answers to questions about the care. About
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half the studies were of each kind. Specificity is a
continuum from a specific referent event (e.g. a particu-
lar visit) or the evaluation of health services in general.
This criterion also split the studies equally. Type of care
refers to the kind of care or service being evaluated.
About half the studies referred to adult ambulatory
care. Dimensionality refers to the different aspects of
medical care inquired about. Most studies (76 per cent)
measured only a few (four or less) aspects (see Section
113).
Hall and Dornan went on to examine the relation
between 16 (methodological) variables that are not
often (or cannot be) varied within the study. They found
no significant difference between studies according to
provider types (MD, non-MD, or both); MD specialty
(internal, family, general or paediatric); authentic (own
experience) or analogous (e.g. vignette); experimental
design or correlational; where (e.g. home or hospital)
satisfaction was measured; how long after an event
satisfaction was measured; part of the world; part of
United States; direct or indirect (see above); and year of
publication. On the other hand, six between-studies
variables did show significant differences. Patients
reported more satisfaction with less experienced physi-
cians; more specific events; particular kinds of care
(compared with care in general); when sampled from a
particular health care system; when fewer items were
included; and with home-grown measures. All except
the first of these findings are interrelated: studies on
particular kinds of care had more specific referents;
studies using specific referent categories more often
draw their sample from a given health care system;
shorter instruments tended to have more specific refer-
ents; home-grown measures were more specific. The
general implication of this analysis is that there is
general disquiet with the provision of health care which
patients find difficult to specify, except in terms of the
qualifications (or experience) of physicians.
 THE MEASUREMENT OF PATIENT SATISFACTION 243

However, despite the herculean attempt of Hall and TABLE 1 Respondents dissatisified overall and those dissa-
Doman to compare across studies, there remains a sense tisfied with explanations given by medical staff (York 1988)
that the methodological variations between studies
vitiate this kind of meta-analytic comparison.49 More- With
explanation
over, even if one were to accept that satisfaction results
Overall given Nos. in cells
can be compared in this way, with the implied sugges-
tion of an underlying unitary concept of satisfaction, the
M F M F M F
absolute percentage satisfied is of limited value; the
interest lies in comparison. The issue then is to decide on 18-24 21 32 21 23 43 53
the appropriate comparator: other authorities; previous 25-44 29 24 23 28 52 121
studies in the same ward/unit/hospital; other wards/
All ages 20 19 19 23 234 379
units/hospitals in the current study? Given that the
questions produce only a narrow range of responses, Source: Carr-Hill et a/.53
this often poses the difficulty of obtaining a large enough
sample to be able, even in principle, to demonstrate a
difference.

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It is more fruitful to examine the ways in which
satisfaction results are sensitive to specific design fea- TABLE 2 Persons satisfied with out-patients' overall service
by gender and age (Wolverhampton 1987)
tures. Four crucial parameters are considered below:
who is interviewed, the timing of the interviews, the type When
of questionnaire used and how satisfaction is rated. interviewed When
Each of these has a major influence on the results and in out-patients interviewed
makes comparisons extremely difficult.50 These factors waiting at home
contribute to the sense of unreliability of thefindingsof
patient satisfaction surveys. M F M F

IV. 1 Choice of population 18-24 82 69 57 69

The choice of population is crucial; thus some argue that
satisfaction surveys should be limited to those who are
currently consuming health services, others that, as the
health service is a public service, the reaction of those
who are not immediately or recent patients/consumers
is also very relevant (see Fig. 1). However, even if only
current patients/consumers are considered, there can be
wide variations in the type of patient interviewed. For
example, one study showed how young females are most
dissatisfied overall, but middle-aged females are most
dissatisfied with the explanations they are given (Table
1).
IV.2 Timing
The timing of surveys may also be of critical impor-
tance. The longer the gap between the use of services and
the interview (or the questionnaire), the greater the
chance of recall bias, of respondents overlooking mat-
ters that affected them during the episode of care, and of
changes in their appreciation of services. Such con-
siderations led Rees and Wallace52 to conclude that
factors relating to the timing of research interviews
'make it difficult to interpret the "meaning" of the
results and once again suggest caution in accepting some
research conclusions about client satisfaction'. For
example, another local study incorporating interviews
both in out-patient departments and at home, suggested
25-44 72 76 39 58
All ages 60 82 59 69
Source: Carr-Hill era/. 53
a clear decay in satisfaction from being 'on the spot' to
being interviewed at home (Table 2).
This is similar to thefindingsof Hall and Dornan that
there is higher reported satisfaction with specific kinds
of care. However, the findings of other studies in the
United Kingdom do not, necessarily, follow the same
pattern (see, e.g. Ref. 31). This variability does not make
interpretation of the findings of satisfaction surveys in
general any easier.
IV.3 Type of questionnaires
Perhaps the most important methodological considera-
tion relates to the type of questionnaire used to acquire
data. It is axiomatic that the questionnaire should not
distort the consumers' view, but achieving this is not an
easy task when the provider perceptions are taken as
paramount.
Respondents can be asked to talk about or comment
on the services they have received or they are asked a
244 JOURNAL OF PUBLIC HEALTH MEDICINE
series of direct questions about their satisfaction with
aspects of those services. This issue was not considered
by Hall and Dornan (their concept of directness refers to
the way satisfaction is assessed). Yet the different types
of question clearly generate different kinds of data: the
first is based on an 'objective' account of what happened
from which we infer satisfaction; the second generates
direct evaluations without necessarily knowing the
referent. Unstructured questions produce different
results, with individuals reporting satisfaction or dissa-
tisfaction when asked directly about different aspects of
care, but not giving them sufficient priority to mention
them spontaneously. Direct questions appear to func-
tion as probes to elicit dissatisfaction with aspects of
care which have less impact than those mentioned in
response to open-ended questions. Both kinds of ques-
tions should be included to avoid under-reporting and
to assess patients' priorities.
IV.4 Rating satisfaction
Some have argued for very simple direct questions of the
form 'what do you think about the doctors/food/nurses/
etc.', with the response chosen from 'very satisfied',
'satisfied', 'dissatisfied', 'very dissatisfied'. However,
reliance on simple portmanteau questions such as these
is problematic. High levels of dissatisfaction on one
aspect of, say, the information given could be masked by
high levels of satisfaction on other aspects. Also, a
change from satisfaction to dissatisfaction may be due
to a small shift in each of the component aspects which is
cumulative or to a large shift of just one of them.
Let us suppose that conditions had improved in one
respect but deteriorated in another. Groups asked
before or after will almost certainly give different
weightings to the two factors. Although an overall
assessment will always be made - even if only implicitly
when action is taken on the basis of expressed dissatis-
faction - this does not imply that anyone did or would
want to ascribe to the weights implied by that assess-
ment. Any proposal for monitoring satisfaction on a
regular basis must be sensitive to the multiplicity of
ways in which satisfaction is expressed and felt by both
patients and staff.
Moreover, simple questions are relatively insensitive,
with responses tending to fall into narrow bands and
being only superficially indicative of high satisfaction
levels. Where a substantially different satisfaction level
is obtained, the cause is likely to be glaringly obvious -
such as a new ward management - obviating the need
for the questionnaire in the first place.
It is also far from clear what is being measured.
Variations in interpreting questions are ironed out
statistically, but this does not resolve the more funda-
mental issue of what such information means, as the
wording of questions does not directly address patients'
experiences.
V Reliability of the findings
The reliability of the findings of satisfaction surveys is
frequently questioned. There are four issues. First, the
level of criticism or dissatisfaction expressed by patients
depends on the context and way in which questions are
asked. Apart from the strictly technical considerations
above, data on consumer satisfaction are comparable
across environments only to the extent that service
consumption coincides. In principle, one can avoid
some of the problem by focusing on generic services but
if the context is very different, it is still difficult to
interpret the results. Similarly, it is important to check
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the respondent's level of 'consumption' because stan-
dards of practice change and those without recent
experience may be basing their responses on socially
stereotyped concepts of providers and of services.
Second, the general perspective adopted by the
studies (the type of questions asked and the topic areas
included) implies that patients do not - or should not -
evaluate clinical practice. Although this is partly
because most studies are designed from the perspectives
of the providers, a further reason is that patients do not
always have the required knowledge. However, studies
of those suffering from chronic conditions have shown
how patients became 'expert' - they tend to become
more critical of, and less satisfied with, the care
provided.54-55 Moreover, ethnographic studies56 show
that patients have clear criteria both for judging the
ability of their family doctors and for evaluating
medical procedures. Finally, patients' reports of infor-
mation-giving by providers have repeatedly been found
to correlate positively with objective data gathered from
taped medical encounters.
An early comprehensive study by Korsch el al?1
examined the relationship between the nature of the
verbal communication between the doctor and patient
and satisfaction. They collected tape recordings, and
conducted a semi-structured interview immediately
after the consultation and a follow-up interview 14 days
later. Satisfaction was not found to be related to any
attributes of the population, to characteristics of the
doctor seen nor to the diagnosis, but was considerably
higher if the doctor was friendly and patient expec-
tations were fulfilled.
Third, the characteristics of the intended and
achieved samples are rarely compared. Ideally, in a
hospital context, sampling should be from discharge
lists (admission lists being incomplete or out of date).
However, apart from practical difficulties, it is more
difficult in a study of retrospective opinions to obtain
 THE MEASUREMENT OF PATIENT SATISFACTION
views on the organizational and psychological experi-
ence of admission or on the social and psychological
needs of long-stay patients. Nevertheless, response rates
can be high with reminders. In fact, the response rates
are, frankly, often appalling. One gem of an exercise
involved the distribution of 105 700 questionnaires with
38 responses; nevertheless, a report was written. Those
commissioning studies seem content with what would
seem very low response rates to a social researcher: a
recent study by the Audit Commission35 of patients'
opinions of day-care surgery made no apologies for a
response rate of 50 per cent which is 'common for this
type of study' (no source cited). In fact, response rates
can be fairly high.58
The practices in calculating response rates are often
bizarre. Variations in the way groups of patients are
intentionally or unintentionally excluded in the report-
ing of results make interpretation of the response rates
very difficult. The example below shows the importance
of clearly specifying both denominator and numerator.
How not to compute response rates
400 registered patients
130 pre-screened as ineligible
40 refuse the questionnaire
200 questionnaires are returned
A high response rate is reported, as 200 question-
naires were returned out of 230 that were accepted.
Those patients who refused ought, of course, to be
included, giving a response rate of 74 per cent (200/270);
but if the intention was to reach all patients then the
correct figure is 50 per cent (200/400).
However, even when the denominator and numerator
are clearly reported it is rare to find adequate commen-
tary on the characteristics of the achieved versus the
target sample and the covariates of non-response. This
is bad practice; positively good practice would involve
the interviewing of a small sample of non-respondents.
VI Qualitative techniques
There is a wide range of possible techniques for eliciting
patient satisfaction. For example, one approach to the
problem of finding sufficient variation in the data for
management purposes is actively to seek out dissatisfac-
tion. This can be done either by probing the satisfied
response more thoroughly in interviews or by employ-
ing one of a range of other qualitative techniques.
Indeed, although this paper has concentrated on quanti-
tative survey methodologies this does not mean that less
formal and/or less technical research methods are to be
devalued.
In the first place, health service managers should
become more aware of the informal data collection that
245
may already be part of their daily routine. Thus,
customer opinions are registered in a variety of forms
such as magazines and radio phone-ins. Obviously, they
are likely to represent the most vocal end of the
spectrum of patient opinions but they can be used to
decide upon the range of possible complaints and
dissatisfactions. Even in the hospital context, the tradi-
tional complaints box is not the only method of trapping
patient opinion; some hospitals have made special
telephone lines available, or instituted a system of
visiting lists. The matron rounds and ward meetings are
other opportunities to hear the patient, and more effort
can be made to ask family and friends what they think.
In some circumstances, it is worth investigating the
possibility of ensuring that these observations and
conversations are systematically reported. It often
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makes more sense to extend these informal methods,
rather than conduct an expensive and potentially incon-
clusive survey.
This is not only because of the expensive and
uncertain payoff of full-scale surveys. It is also because
the questionnaire method only obtains replies to a series
of pre-set questions, not the patients' considered (or
spontaneous) views on the issues which concern them,
whether as current users or as members of the public.
Once the fieldwork is over, there is a considerable
temptation to forget that what are confidently described
as respondents' views are only their replies to questions
devised by the researcher and not necessarily the
patients' own views and priorities. Thus, it is common-
place to observe that health service policy has been
steered by providers' perceptions and definitions of
good practice. It is important that those engaged in
consumer research, if they are to obtain systematic
information about 'consumer views', do not fall into a
similar trap.59
Second, there are specific techniques which have been
developed to identify where things go wrong. Two
examples are given here. One possibility is the focused
group discussion, where a relatively homogeneous
group are invited to discuss a topic. They are guided
through the topic by a facilitator and their ideas are
recorded by a rapporteur. A variant of this is the
nominal group process, where participants are asked to
write down their ideas independently and before any
decision. This is a particularly useful method in situa-
tions where one suspects that the target group is likely to
be reticent.
Another possibility is critical incident analysis, an
approach which aims to discover both the patients'
agenda and their definitions of good practice. Based on
methods used infieldsas diverse as operational research
and phenomenological sociology, it centres on the
patients reconstructing what amounts to a diary of their
246 JOURNAL OF PUBLIC HEALTH MEDICINE
TABLE 3 Breakdown of consumer feedback survey studies
Community health 10
Elderly 15
In-patients 35
Maternity 47
Out-patients 32
Population survey 22
Women's health 13
Others 56
230
Source: Dixon and Carr-Hill (Ref. 60, p.2).
hospital or other care experiences. It asks them to report
what was important, notable, strange and worrying -
anything which stood out in their memory, from the
friendliness of the porter who guided them past incoher-
ent signposting, to the anxieties of being left sitting
alone on a bed in a ward.
VII Patient satisfaction surveys in
practical health care contexts
In principle, of course, all these homilies/lessons should
be applied to any practical survey. The reality is rather
less impressive. A meta-analysis of 230 locally based
UK surveys - nearly all unpublished - was carried out
by Dixon and Carr-Hill.60 Their review contained the
breakdown given in Table 3.
VII.I. Out-patient surveys
Among out-patient studies, waiting times are still the
main concern; around half the studies collect little other
information, although this is now changing. Of the 32
studies reviewed, 19 cover all or most out-patient clinics
at one or more hospitals whereas eight concentrated on
individual clinics. However, as over half the single
clinics studied used questionnaires not tailored to local
circumstances and most of the multi-clinic work makes
no attempt at systematic comparison, one can only
conclude that the number of clinics studied was more a
consequence of chance than of explicit design.
On the other hand, most studies have some explicit
aims, ranging from sampling opinions before making
changes61 to general evaluation and identifying areas for
improvement.62 Although some District Health Author-
ities (DHAs) would clearly like to collect evidence to
encourage particular consultants to improve their
reception arrangements and communication practices,
few have even been prepared to record the consultant's
name on the questionnaire.
Waiting time studies, although a principal concern of
most patients and subject to Department of Health
guidelines, are inevitably a major research area. How-
ever, as anyone who has conducted a waiting time study
will know, the idea is much simpler than its execution.
Most studies come up against at least some of the
following problems:
(1) How to define waiting time in clinics in which
patients have to undergo tests and treatment in
other departments.
(2) How to obtain reliable answers to detailed time
questions.
(3) How to collect questionnaires or conduct interviews
at the end of a visit when patients' waiting times are
known, but when patients may be upset, not
revisiting a central reception area, and rushing for
transport. Should one accept the reduced response
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rates and possible errors of recall when question-
naires have to be returned by post?
(4) How to ensure that only patients are contacted, not
friends, relatives and others in the waiting areas;
also, how to guarantee that people are contacted at
the appropriate time - usually after their appoint-
ment (Ref. 60, p. 19).
A wide variety of data collection methods have been
attempted and affect the actual though perhaps not the
intended sampling frame. In consequence, response
rates are difficult to interpret, although many studies
report 70-80 per cent response rates if research assist-
ants are on the spot.
Few studies report success in changing consulting
behaviour, although several have reported reactive
effects during a study. General out-patient question-
naires using positively biased questions of the type 'In
general were you fairly satisfied with ...? YES/NO'
were, unsurprisingly, least likely to produce specific
policy proposals. On the other hand, most reported out-
patient surveys have helped achieve some sort of
beneficial change.
VII.2 In-patient surveys
In-patient surveys were started in the late 1960s by
academics and groups such as the King's Fund. During
the 1970s and early 1980s, they were taken over by
Community Health Councils (CHCs). Indeed, DHAs
were so inactive that Leneman et al.63 commented that
one of the only two significant features of a 1983 study
was that it was entirely done by a DHA. Post-Griffiths,
the picture has considerably changed, with health
authorities now responsible for the majority of in-
patient surveys, albeit with some practical help from
CHCs (Fig. 4).
Some of this early work by health authorities was
little more than gestural, using a standard question-
naire, distributed haphazardly by ward staff, with no
 THE MEASUREMENT OF PATIENT SATISFACTION
70 r and has been used to study a wide range of topics from
bv^DHA
56 ^ CHC/DHA
I • CHC
42
28
14
Area A Area B Area C
Date of studies
FIGURE 4 Responsibility for consumer feedback surveys.
clear objectives nor sense of how the information might
be used. There was little tangible reporting and high
percentage satisfaction levels were juxtaposed with
patients' critical comments. However, standards are
improving.
Five types of studies were received at York:
(1) 11 which tackled specific topics with locally devised
methods;
(2) three which used specialized questionnaires, such as
those in Raphael's Old people in hospital (1979) and
her Psychiatric hospitals viewed by their patients
(1972);7
(3) 15 were based on the King's Fund general question-
naire, or a very close approximation - three using
this questionnaire entirely for interviews;
(4) two studies used the University of Manchester
Institute of Science and Technology (UMIST)/
HPAU questionnaire;
(5) a final group of 14 studies had similar aims to the
King's Fund, but devised their own general ques-
tionnaires with from 10 to 40 questions.
Locally devised surveys on specific topics were amongst
the most purposeful and effective. Their methodology
was often flexible and ingenious, and often permitted
more labour-intensive methods which gave higher-
quality data. Surveys using established specialized ques-
tions were for groups such as children; the mentally ill
and the elderly are still relatively ignored. The King's
Fund general questionnaire, which contains 40 simple
questions, is widely used. However, it tends to encour-
age positive responses, especially as it is distributed on
the ward; and although it is very simple, it cannot be
completed by all patients.64 The questionnaire devised in
the Department of Management Sciences at UMIST is
much longer (80 questions on 32 pages) and has been
extensively piloted. It comes as part of a package, with
guidelines for distribution and a reporting system. The
questionnaire is usually administered post-discharge,
247
previous hospital experience to after-care arrange-
ments. Despite being recently revised, it remains long
and presumes a high level of (English) literacy. Finally,
locally produced general in-patient questionnaires tend
to run into all the problems which piloting is designed to
avoid.
The UMIST/HPAU package guarantees results and
can be used as a regular audit device. However, it does
not give the sort of direct feedback that comes from
open questions, and it is unlikely to identify specific
local problems.
Attempts are being made by CASPE to design a
continuous monitoring system. Despite considerable
effort and resource inputs, these are still at the pilot
stage. The basic problems are the lack of clarity in the
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objectives of using a standard package for continuous
monitoring, the presumption that management is able
or prepared to respond to the volume of information
generated,59 and the focus on empowering manage-
ment34 rather than patients.65
The CASPE project purports to empower manage-
ment to meet publicly expressed needs. The alternative
is that the requirement to be responsive to the con-
sumer/patient should lead to patient-led monitoring
and the empowerment of patients, at the same time as
enabling managers and practitioners to fulfil patients'
expectations. This would involve other kinds of surveys
employing a more participative methodology, or other
methods such as local planning for patient advocates
and more regular management contact with patients.
There are clearly difficulties in proposals based on
surveyfindingsbeing put into practice. Even the clearest
and most sensible proposal will not have an effect when
the decisional structure is unable or unwilling to accept
this sort of input; if the relevant management denies or
devalues the legitimacy of the survey's instigators; or if
the staff who have to implement the policy are unsym-
pathetic. Also, such proposals may simply fail for lack
of resources. It is depressing that people still devote very
considerable amounts of valuable time and effort to
types of research which cannot possibly hope to achieve
their aims.
VIII Conclusions and recommendations
There are sensible and substantial criticisms to be made
of satisfaction studies. Not all are appropriate, however.
There is, for example, no reason why a survey about
satisfaction in general should give the same overall score
as one about satisfaction with a particular aspect of
care; it is not surprising that reported satisfaction levels
with the same incident decay or improve over time.
Equally, we know from other fields of research that
248 JOURNAL OF PUBLIC HEALTH MEDICINE
different kinds of questions (closed or open) give
different answers. Moreover, it would be Utopian to
suppose that a 'uniform set of guidelines on consumer
satisfaction surveys' could be agreed, but the following
points should be considered more widely.
VIII.l Existing studies
Reporting
There has to be more complete reporting of the
characteristics of the sample studied as well as of the
'satisfaction' results obtained. Too often, it is simply
impossible to know who was the target population (see
Fig. 3), or to understand how satisfaction varies among
the population.
Response rate
It seems not to be realized that the response rates have to
be high to give credible results. First, as with other
surveys, where the response rate is low, there is an
inevitable risk of bias; second, but also because overall
levels of satisfaction are usually fairly high, only a small
fraction of the population can potentially express
dissatisfaction and they may also be non-respondents.
Standardized instruments
Any health services manager should beware of 'stan-
dardized' instruments. The reasons are simple: context
and objectives differ.
VIII.2 New studies
Minorities
There have been very few studies of minority groups,
whether denned in terms of patient or of treatment
characteristics. For management purposes, it would be
inappropriate to assume simply that results obtained on
a general population are transferable.
Coverage of satisfaction
The 'theory' underlying existing satisfaction studies is
inadequate. Partly in consequence, several aspects of
'satisfaction' simply have not been studied.
Method
To date, nearly all the studies have been one-off cross-
sectional studies of customer satisfaction with a particu-
lar service, with a few before-after studies. There have
been no 'proper' randomized control trials.
More generally, the search for the 'holy grail' of a
standardized patient satisfaction questionnaire should
be discouraged. Not only does satisfaction mean differ-
ent things to different people at different times, but
patients are differentially satisfied according to the
structural characteristics of the specific medical
encounter. Measurement here, as in other areas, must be
not only informed by theory but also conditioned by
context.
Acknowledgements
Thanks are due to Paula Press for transforming my
scrawl into something apparently coherent; to Paul
Dixon for frequent very productive debates on the
nature of consumer satisfaction and for organizing the
review of some 300 consumer feedback surveys which
forms the basis for some of the argument in Section IV;
to the Department of Health for funding the project
'The NHS and its Customers' which is the basis for some
of the argument in Sections II and III; and to the
Downloaded from jpubhealth.oxfordjournals.org by guest on March 13, 2011
Economic and Social Research Council for supporting
the author while he was working on this paper.
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