Patients’ Satisfaction with Healthcare Provision in an Out-patient Setting in Malta

Introduction

The Maltese Healthcare System

Malta’s National Healthcare Service (NHS) is primarily funded through general taxation and seeks to provide free healthcare coverage to all residents.¹ Most healthcare services are hospital-based, with in-patient and out-patient services primarily delivered through public hospitals. Primary care services are offered through health centres or community care clinics, which seek to provide various multidisciplinary primary care services at a community level.²

The private sector supplements public health services through private hospitals, clinics, and General Practitioner (GP) services. Although the public and private sectors function independently, the government has several public-private partnership agreements to support public services. Such agreements generally involve using private facilities to shorten waiting lists for specific procedures and investigations.

Primary care services are the first level of care and an entry point to the health care system. GPs have a gatekeeping role by recognising what can be treated within primary care and what requires referral to higher levels of care.^3,4 In Malta, GPs may refer patients for specialist review within the public services by filling in an online referral form. Specialist appointments are then issued on an out-patient basis according to the case's urgency. Patients, however, also have the option to see a medical or surgical specialist in the private sector. Private specialist appointments can often be set up with or without a GP referral; thus, patients can set up an appointment directly with a chosen specialist.

Public healthcare services in Malta are free at the point of use, but notwithstanding this, the use of private healthcare services remains high. This is particularly evident in primary care, where the private sector is estimated to cater to over two-thirds of the demand for services.^3,5,6 Most private primary care services are offered through solo/independent practices; only a few group practices exist.^3,7 Regarding secondary care, a few private hospitals and clinics provide in-patient services, medical imaging services and theatre procedures within the private sector. Patients using private healthcare services can pay out-of-pocket or through voluntary health insurance policies.

Patient Satisfaction in Healthcare

Patient satisfaction can be defined as the state of happiness that the patient experiences when using a healthcare service.⁹ This became an important measure of efficiency and effectiveness and is a standard for evaluating healthcare services.⁹ Most complaints in healthcare settings relate to interpersonal aspects of care and communication rather than clinical or technical errors.¹⁰ The patient’s experience and satisfaction within the healthcare system are multifactorial. They can be linked to both provider-related factors (such as facilities, interpersonal skills, etc.) and patient-related factors (such as age, personality, educational level, etc.).¹¹ As a result, collecting data relating to the patient’s care experience remains pertinent to identifying and addressing such issues.

A difference in patient experience and satisfaction between Malta's private and public healthcare services has been reported.^12,13 This difference may explain the reported higher rate of utilisation of private services.

This study used secondary data analysis from the European Health Interview Survey (EHIS)¹⁴ to identify patterns in health service use and possible differences in patient satisfaction and experience between the public and private sectors.

Methodology

The EHIS is held every five to six years in all EU countries. It aims to obtain valuable data on health behaviour, healthcare use, and morbidity across all EU member states.¹⁵

The EHIS was last conducted in Malta in 2019/2020. At the time of data collection, the target population was all individuals aged 15 and over who resided in private residences in Malta and Gozo. The National Statistics Office extracted the sample, which consisted of a random sample stratified by age, gender, and residence locality. The effective sample size reached was 4413 out of an eligible 6430 (response rate of 68.6%), with the target sample size being 4000 respondents.

A descriptive secondary analysis of data collected through the EHIS is presented to provide an updated insight into the use of public and private healthcare services regarding visits to GPs and medical/surgical specialist consultations. Data on the patient experience and overall consultation rating were analysed to determine differences between the private and public sectors. This is then discussed in the context of existing research and assessed for any significant differences between the two sectors. Digital Supplementary File 1 highlights the EHIS questions which were used for the analysis.

Two questions in the EHIS (HC.9 and HC.18) asked participants when they had last visited a GP and medical or surgical specialist, respectively. Participants answering these questions could choose from the following answers: ‘in the last 12 months’, ‘more than 12 months ago’, or ‘never’. The other questions included in the analysis (HC.13-HC.17 and HC.22-HC.26) were based on a Likert-type response where patients could rate their experience of care for the domains explored, eg ‘Yes’; ‘Yes to some extent’; ‘No’; ‘No, definitely not’; and ‘Do not know’.

For the analysis, primary care (GP) consultations are considered within a clinical setting (in-office) since the questionnaire did not directly enquire about patient satisfaction in the context of home GP visits.

Statistical Analysis

Data were analysed using IBM® SPSS® v.28. First, a descriptive analysis was conducted to identify trends and patterns in the data. Then, statistical testing was conducted to determine whether there were significant differences between the public and private healthcare sectors for each domain.

Chi-squared testing used a p-value of 0.05 and a 95% confidence interval to determine significance. Fisher's exact test was used for small numbers (values less than 5). Significance testing was carried out for the public and private sectors in primary care services and specialist services, respectively. Primary care and medical/specialist services were not compared directly since they consist of separate specialities and represent two different levels of care.

Results

Table 1 summarises the responses given for the overall rating of the last medical consultation (questions HC.17 and HC.26).

The level of satisfaction in terms of consultation times, explanation of treatment, opportunity to ask questions, and involvement in care was high throughout. The percentage ratings (aggregate responses) of each of these domains (questions HC.13-HC.16 and HC.22-HC.25) are illustrated in Figure 1 & Figure 2.

Figure 1

Responses for Questions HC.13 - HC. 16: GP Consultations

Figure 2

Responses for Questions HC.22 to HC.26: Medical/Surgical Specialist Consultations

Primary Care (General Practitioner) Services

77.2% of participants had visited a GP in the previous 12 months. 69.4% visited a private GP, and 30.5% visited a health centre doctor in the same period.

In terms of length of consultation (HC.13), 96.4% of those visiting a private GP felt that consultation time was enough as opposed to 91.5% of those who had visited a health centre doctor (p< 0.001). 96.9% of those visiting a private GP felt that things were explained understandably (HC.14). This was slightly less for health centre visits, with 90.1% giving a positive response (p<0.001). 96.9% of those visiting a private GP agreed they were allowed to ask questions (HC15). This dropped to 79.1% for health centre GP visits (p<0.001).

A lower satisfaction score was noted in terms of involvement in care decisions (HC.16), to which only 87.7% (private GP) and 79.9% (health centre GP) answered ‘yes’ or ‘yes, to some extent’ to this question (p<0.001).

Secondary Care Specialist Services

The satisfaction scores for primary care services are congruent with those obtained for secondary care specialist visits.

Visits to medical or surgical specialists (secondary care) were less than GP visits, with 34.3% of respondents having visited a medical or surgical specialist in the previous 12 months. 25.6% had visited a secondary care specialist doctor within the private sector, and 18.4% visited a specialist within the government health services.

Responses for question HC.22 on the length of consultation times for secondary care visits were similar to those obtained for GP visits, with 93.8% (private specialist) and 90.5% (government specialist) agreeing that consultation time was enough (p <0.001). 94.1% of respondents felt things were explained understandably (HC.23) during private secondary care specialist visits compared to 91% in the public sector (p=0.016).

For secondary care specialist visits, there was a lower satisfaction for opportunities to ask questions (HC. 24) compared to the other questions posed, with 90.4% (private practice) and 86.5% (government specialist) agreeing that they could ask questions during the consultation (p=0.019). Similarly, scores were lower for involvement in care decisions (HC. 25) during secondary care specialist visits, with 87.5% and 84% answering ‘yes’ or ‘yes, to some extent’ for private secondary care specialist and government secondary care specialist visits, respectively (p=0.033).

Despite the high overall satisfaction rates, there was a statistically significant difference between the public and private sectors. The private sector scored more positively on the questions posed in the EHIS.

Discussion

EUROSTAT¹⁶ data shows that an average of 81.4% of the population across the 27 EU member states consulted a medical doctor in the previous 12 months.¹⁶ In Malta, an estimated 79.9% of the population had consulted a medical doctor in the last 12 months, making it slightly less but close to the European average.

Data from the EHIS demonstrates that the demand for healthcare services is high, with 77.2% of respondents having visited a GP the previous year. 34.3% had visited a medical or surgical specialist in the same period. Although these rates are similar to the EU average, there was a slightly higher rate of GP consultations in the previous 12 months (EU average of 75.6%) and a lower rate of specialist consultations (EU average of 51.9%).¹⁶ This may indicate higher accessibility to primary care services in Malta.

The dependence on private primary care services is still evident. Indeed, 69.4% of respondents had visited a private GP in the previous 12 months compared to 30.5% who had visited a government GP in the same period. This is consistent with earlier data suggesting that the private sector caters for 70% of the primary care services in Malta.^1,3,12,13 Similarly, there was a higher rate of specialist consultation in the private sector (25.6%) than in the public sector (18.4%), but this difference is much less pronounced.

Although the demand and rate of utilisation of services do not directly reflect clinical outcomes or care, this data shows that overall, Maltese patients tend to consult more private doctors, especially for primary care issues. Differences between the two sectors may explain the reliance on private primary healthcare services. Continuity of care is considered one of the core values of general practice. The public health centre system does not have a well-established follow-up or GP registration system, and most public GP services are offered on a walk-in basis. In the private sector, patients can choose their own doctor and have a higher level of continuity of care, allowing them to establish a patient-doctor relationship with their GP.⁷ Patients using health centre (public) services cannot form a long-standing patient-doctor relationship as they cannot get regular care from the same doctor. The importance of continuity of care in primary care is also emphasised by the World Organisation of Family Doctors (WONCA), which emphasises that patients should ideally have a named family doctor to improve the quality and effectiveness of care and provide consistent and personalised healthcare.⁸

Recently, several initiatives were launched to improve public primary health services, such as introducing electronic patient records and new collective agreements for doctors. Nevertheless, the resources available within the public sector, especially regarding staff, still need to be improved compared to the workload and demand for services. On the other hand, it is also noted that private practitioners work with much fewer resources (e.g. access to investigations, results, etc.) and often for longer hours compared to those working in the public sector. It may be argued that these factors are also reflected in patients’ experience and satisfaction, as discussed below.

Patient Satisfaction

Patient-centred care has become an essential aspect of healthcare services across EU countries. It has been widely implemented to identify patients’ expectations and needs and improve the quality of care.¹⁷ As previously highlighted, identifying factors affecting patients’ satisfaction and experience is critical to developing patient-centred policies to improve patient care.

In Malta, the evaluation of patient-centred care has been previously explored. The National Health Interview Survey (NHIS) (2002) had already reported a high rate of utilisation of private services and higher satisfaction in the private sector.¹³ A study by Agius later confirmed the difference in patient satisfaction between public and private primary care services, which was highly significant.

In our analysis, data from the EHIS shows that patients are satisfied with the services they receive across all sectors, as reflected in the high overall rating of their last consultation. However, A significant difference exists between the public and private sectors for both GP and specialist visits, with higher satisfaction rates in the private sector. The questions in the EHIS explore several interpersonal domains which may influence patient satisfaction. Indeed, although there was an overall positive rating across all questions, the difference between the private and public sectors persists throughout the analysis.

Regarding GP visits, it is noted that GPs scored very well for consultation time and explanation in an understandable manner. Scores for health centres were, however, lower with statistical significance. The lowest score was in terms of involvement in decision-making, rated as ‘yes’ for 87.7% of private GP visits and 79.9% for health centre GP visits. Only 79.1% of respondents agreed they were given enough opportunity to ask questions during their last health centre visits compared to 96.9% during their previous private GP visit.

While the statistical difference was achieved for all questions, health centre doctors scored notably lower regarding the opportunity to ask questions and involvement in care. Such results are congruent with a study by Pullicino et al, in which private primary care services scored higher in terms of ‘continuity of care’, ‘comprehensiveness of care’, and the application of a biopsychosocial approach and poorer in terms of access to care – accessibility and out-of-hours services.¹⁸ A more in-depth and explorative qualitative analysis of the factors contributing to these issues might be warranted to address these interpersonal aspects.

The lower rating score noted in question HC.16 on involvement in decision-making was similarly noted for visits to secondary care medical/surgical specialities. Indeed, 87.5% (private specialist) and 84% (government specialist) of respondents agreed that they were involved in decisions about care during their last specialist visit. Such results may indicate that patients wish to be more involved in decision-making and may signify the need to raise awareness among Maltese practitioners on patient-centred care and involvement in care.

Interpersonal aspects of consultation, including the time allocated, involvement in care, and attention given to the patient, all correlate positively with the quality of the consultation.¹⁷ Data from the Organisation for Economic Co-operation and Development (OECD) is congruent with the data obtained in Malta. Indeed, the OECD reports that most patients report positive interactions with doctors. Similar to Malta, the OECD data shows that the majority of patients felt that the doctor spent enough consultation time with them (EU average 84% for 2020), provided easy-to-understand information (EU average 90.5% for 2020) and involved them in care decisions (EU average 82.1% for 2020). The Netherlands scores exceptionally high in these three aspects.¹⁷ While it is difficult to compare due to possible variations in culture, survey coverage and response rates¹⁷, differences in the healthcare systems might also explain the higher satisfaction rates in the Netherlands. The Netherlands has a higher expenditure per capita on health and lower out-of-pocket spending than the EU average, with healthcare services funded through a regulated framework of mandatory insurance policies.¹⁹ The country has a robust primary care system, with a reported low hospital admission rate and among the lowest mortality rates from preventable and treatable causes in the EU.¹⁹

Our analysis confirms that patients' experience differs between the public and private health sectors, and patients tend to report higher satisfaction in the private sector. The data is congruent with previous studies evaluating patient satisfaction in primary care, as discussed above.

Despite the high overall satisfaction rates, the analysis supports the need for an in-depth explorative evaluation of healthcare services to ensure that all stakeholders’ perceptions, needs, and demands (care providers and patients) are addressed. Further research should focus on identifying possible solutions to shift resource utilisation and maximise the use of primary care, with an emphasis on patients’ experience and satisfaction.

Limitations

The study involves a secondary analysis of quantitative data and does not provide qualitative insight into the reasons for any discrepancies between public and private healthcare services. The original interview was aimed at obtaining general data on several health indicators and was not solely focused on access to and experience of the healthcare services.

Conclusion

The analysis confirms the high demand for healthcare services in Malta, mainly primary care services. It once again highlights the heavy reliance on private primary care services and the discrepancy in experience and satisfaction between public and private services. Nevertheless, the data indicates high satisfaction with the attributes explored across both sectors.

While the data obtained in the EHIS is quantitative, it can be postulated that patients appreciate a patient-centred approach whereby they are listened to and allowed to understand, ask and make informed choices. The significant difference between the public and private sectors supports this. The main prima facie differences between the public and private sectors are related to how the private sector services can be accessed and how they are provided. This analysis supports further exploratory evaluation to identify ways the gap in patient satisfaction between the public and private sectors can be reduced.

Summary Box

What is already known about the subject

• Patients’ experiences and satisfaction have become necessary to assess the quality of care.
• There is a high utilisation of private health services, especially in primary care.
• The two health services reported a difference in patient experience and satisfaction.
• The EHIS provides data on patient experiences regarding GP and secondary care medical or surgical specialist visits.

What are the new findings?

• Data from the EHIS was analysed, and the high demand for healthcare services was confirmed.
• Reliance on private primary care services is still high.
• Overall, the domains explored throughout both sectors had high satisfaction rates for GP and secondary care specialist visits.
• A difference in patient experience and satisfaction between the public and private sectors is confirmed again.
• GPs and secondary care specialists scored worst regarding patients' involvement in decisions about care and treatment.

Abbreviations

EHIS European Health Interview Survey

EU European Union

GPs General Practitioners

HCs Health Centres

NHS National Health Service

OECD Organisation for Economic Co-operation and Development

References

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