An area's population profile shapes patients' perceptions of service quality, with greater diversity bringing a wider array of demands. This suggests trusts should make more effort to understand their public

Patient perception matters more than ever, but a new analysis confirms once again that some trusts will never perform as well as others in terms of how they are regarded by their patients. That patients are mostly very positive about their treatment overall is well known, even if they can also point to many much needed improvements. But what is also clear is that, particularly in primary care, place matters.

Ipsos MORI's latest report, Frontiers of Performance in the NHS, looks across communities and explores what is behind different levels of patient perception. It shows that trusts serving certain communities will always find it much harder to achieve high levels of patient satisfaction than others.

Let's look at different sectors in turn. First of all, ratings of primary care trusts in terms of how the public rates GP performance. What patients think of primary care services has very little to do with objective performance measures such as standardised mortality ratios (death rates after treatment) or how much is spent per patient. Instead, the nature of local communities has far more to do with patient ratings. PCT services in areas with high ethnic fractionalisation (the range of different ethnic groups in an area), high deprivation and a young population nearly always receive lower ratings of satisfaction than those serving wealthier, older and less diverse populations.

In particular there is a strong relationship between serving a very mixed population and overall ratings of GP services for that area. While it does not prove a causal relationship, the 76 per cent correlation between our index of ethnic fractionalisation and GP satisfaction scores is strong. In diagnostic work in areas like Newham in London, we find that part of the challenge it reveals is not just greater need in more diverse areas, but also more diverse expectations. If an older Asian patient waits a few hours their reaction will often be very different from that of an older white patient, because of cultural differences in expectations.

Older white people in Britain, for example, do not expect to be treated with deference in the way that some older Asian communities traditionally treat older people.

Independently of ethnic diversity, there are also lower scores for deprived areas. Consistent with similar patterns in local government, these scores highlight the impact of place.

Brilliance is relative

By looking at all the factors that relate to patient perception in PCTs, we can predict patient ratings with some accuracy, simply by knowing the characteristics of the local population the PCT serves, which stands out as more significant than individual aspects of care.

This means that when looking at patient perception of PCT services, it is important to take into account local factors. Brilliance looks different in different places. For example, Newham PCT is consistently among the lowest rated PCTs in the country and serves a highly deprived and fractionalised community. In fact, there are no PCTs in England with very fractionalised populations that achieve levels of satisfaction equivalent to those that serve the most homogenous populations.

Taking the analysis further, once these factors are considered, Newham PCT is in fact achieving levels of patient satisfaction above those that might be expected, given its situation. Overall, the top performing PCTs, having allowed for local conditions, are shown in the table below. Many of these are not the ones we would naturally expect to see in this type of league table.

It will be useful for managers and other interested parties to consider those that manage to rise above their local circumstances and perform particularly well, including again those such as Lambeth PCT, where GPs achieve the highest index performance of any PCT.

Dignity and respect

In the acute sector, once again, we find that spend per patient and mortality ratios have little relationship with patients' perception of their care. The nature of place has less impact, although as with PCTs and indeed ratings of the NHS by non-patients, London trusts face particular challenges, as do trusts serving younger, more ethnically fractionalised populations.

As in 2004, the last time this research was carried out, for a limited number of acute trusts individual aspects of care matter most for patient experience. Trusts that can get these issues right outperform those that do not, even after allowing for local conditions.

There are three main drivers of overall inpatient ratings: treating patients with dignity and respect, involving them in decisions and the cleanliness of the hospital room or ward. Examining the concept of dignity and respect confirms the importance of involving patients in treatment decisions, the importance of privacy of treatment and pain control. Understanding what these issues mean for specific staff behaviours, organisation and communication is key. They reinforce the need for the NHS to put more effort into allowing staff to deliver. For example, there is a strong relationship (57 per cent correlation) between patients feeling doctors communicated effectively and overall perception of care.

Having taken on board the factors that make a difference, we have examined acute trusts in depth, looking at those that perform best and worst, after allowing for the different populations they serve. The analysis highlights how many London trusts, despite the challenges of the communities they serve, are performing much better than raw scores would indicate. (Other London trusts in the top 20 include King's College Hospital foundation trust and Whipps Cross University Hospital trust.)

It is reasonably clear what acute trusts with high performance indices, such as Bromley Hospitals and Newcastle Upon Tyne Hospitals foundation trust, are doing to achieve these levels. As well as basic hygiene factors, above all it is clear that patients want to be kept informed throughout their treatment and to be involved in any decisions. This is so strongly associated with overall ratings and with ratings of dignity and respect - where these trusts have outstanding performance - that any trust that has not brought staff into major actions to clearly deliver these factors will face huge challenges. Building core actions into standard routines and behaviours is absolutely vital. When one looks at the worst performing trusts, they are lacking on these points.

But for all NHS institutions and especially PCTs, understanding the nature of place and the challenges it implies for your trust is key. What is so encouraging is that despite huge differences in communities, the best trusts can rise above them. More focus on key aspects of care that matter would allow more to do so.

For a free copy of Frontiers of Performance in the NHS, which provides an analysis of every English trust, email