Patient feedback on services: a questionnaire survey approach infarction.Case-controlandcase-crossoveranalyseswiththeStockholmheartepidemiologyprogramme(SHEEP).JournalofEpidemiologyandCommunityHealth,

AIMS AND METHOD The aims of the project were to develop a simple, low-cost patient 
satisfaction questionnaire with face validity and to obtain patient feedback 
on a range of service areas in a community addiction team. A questionnaire was 
designed and revised after feedback from multidisciplinary team members and a 
pilot sample. The questionnaire was distributed until 100 correctly completed 
forms were received. RESULTS The survey took approximately 30 h of authors’ time from commencement 
to completion and costs were minimal. The majority of the 12 areas evaluated 
were rated by patients as good or very good. Overall quality of care was rated 
as good or very good by 88% of participants. There was no enthusiasm in this 
sample for more active participation in service development. CLINICAL IMPLICATIONS All National Health Service staff and services are now enjoined to engage 
with service users and carers for the purposes of evaluation and development. 
Simple, affordable methods for obtaining such information about community 
services can contribute to this process.

The aims of the project were to develop a simple, low-cost patient satisfaction questionnaire with face validity and to obtain patient feedback on a range of service areas in a community addiction team. A questionnaire was designed and revised after feedback from multidisciplinary team members and a pilot sample. The questionnaire was distributed until 100 correctly completed forms were received.

RESULTS
The survey took approximately 30 h of authors' time from commencement to completion and costs were minimal. The majority of the 12 areas evaluated were rated by patients as good or very good. Overall quality of care was rated as good or very good by 88% of participants. There was no enthusiasm in this sample for more active participation in service development.

CLINICAL IMPLICATIONS
All National Health Service staff and services are now enjoined to engage with service users and carers for the purposes of evaluation and development. Simple, affordable methods for obtaining such information about community services can contribute to this process.
Providing high-quality services for the people that need them is the purpose of every public service organisation. According to the principles of clinical governance 'NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which excellence in clinical care will flourish'(http://www.dh. gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ ClinicalGovernance/fs/en). The General Medical Council's revalidation process emphasises providing a good standard of practice and care to the patients (http://www. gmc-uk.org/doctors/licensing). Individually, appraisal, revalidation and clinical excellence awards increasingly demand 'evidence' that doctors provide good clinical care. Corporately, organisations increasingly need to demonstrate to commissioners that they are responding to the needs of patients and carers. Patient involvement in service provision is beneficial for the service user as well as the service provider (Department of Health, 2004).
Conducting a patient survey is a simple method for obtaining information from service users about their perception of the positive and negative aspects of a service and might be one of the only means for clients to express their needs and views (World Health Organization, 2000).

Method
An appropriate questionnaire framework was identified (PSQ-18; http://www.rand.org/health/surveys___tools/ psq/index.html; see also Marshall & Hays, 1994) and a questionnaire was then designed to cover the most important elements of the service under consideration, recognising the needs to be as succinct and have as much face validity as possible. The questionnaire was revised following feedback from the multidisciplinary team. A pilot survey of 10 patients at one service site showed that participants found the questionnaire understandable, simple and quick (less than 5 min) to complete, requiring no further changes. The final version was limited to 12 questions about different service areas with space for additional comments. (A modifiable electronic version of the questionnaire is available from P.S.K.) A separate sheet was distributed asking participants to give their address and telephone number if they were willing to be contacted regarding their answers, or improvements to the service, or if they wished to be sent a copy of the results. Two envelopes were provided for the separate return of sheets to ensure anonymity. Participants were asked to return the completed sheets to the reception staff/clinician, or place them in boxes in waiting areas.
The survey was conducted with patients of the Specialist Community Addiction Services, the major health and social care service for people with drug and alcohol problems in Oxfordshire. Questionnaires were distributed to all central and satellite service sites and offered to patients by reception staff and clinicians, with a covering letter. Questionnaires were also sent with stamped addressed envelopes to clients at rehabilitation centres. The survey began in May 2004.

Results
The target sample size was reached by early June 2004; 136 questionnaires were sent out with the intention of collecting 100 correctly completed replies; 6 of the first 100 returned were incomplete and therefore replaced with the next 6 received.
The majority of respondents were aged 20-40 years; 90 respondents were White; 63 respondents were male. The majority of respondents were referred because of drug problems and had been seen on a number of occasions before completing the survey. Responses were obtained from each of the sites where questionnaires were distributed.
Details of responses to the 12 questions are given in Table 1. The majority of participants rated each item good or very good; 5 or more respondents (5%) rated 4 items as poor or very poor. These were the 'waiting area' and the 'time spent waiting', the 'consulting rooms' and the 'information' provided. There were 88 participants (88%) who rated the overall quality of care provided as very good or good.
Space for comments was used by only a minority of respondents and very much reflected the overall tenor of the feedback scores. Entries range in tone, for example: 'The counselling rooms are horrible, plain and boring. Don't feel comfortable, so you don't feel in a place to talk openly and honestly.' 'Great service! Thank you for your help, keep up your good work.' There were 33 respondents who asked to be sent a copy of the results; 11 volunteered to be contacted by telephone about future service development. Those that could be contacted made suggestions about improvements to the waiting areas and interview rooms, and the information leaflets that they thought should be made available. The clients were offered opportunities to be involved in further discussions and at the stage of implementation of changes, but unfortunately none was interested in any further involvement.

Discussion
The Department of Health in England is moving towards the patient playing a major role in the development and improvement of services. It is also the duty of everybody involved in health provision to keep the individuals to whom the services are provided involved and consulted (Health and Social Care Act 2001). The National Audit Commission has also recommended that existing clients' satisfaction with the treatment they receive should be taken into account when commissioning drug treatment services for adults (Audit Commission, 2002).
The survey took less than 3 weeks to conduct. The questionnaires were simple, taking approximately 5 min to complete and most participants did not have a problem completing them. The response was reasonably good at 73%, as it is known to be difficult to engage those who misuse substances (Kay & Peters, 1992;Fountain et al, 2000). The costs of the survey were minimal amounting to perhaps 30 h of planning and coordinating, but following the outline model presented here would significantly reduce the time for replication. The only other original papers Kumar & McBride Patient feedback on services: a questionnaire approach costs were for stationery, photocopying, postage and follow-up telephone calls. The main weakness of the design is the lack of evidence for reliability for the questions asked. Inevitably, those people who, for whatever reason, do not attend the service as currently configured could not contribute to the feedback process. The strengths of the survey method are the simplicity and face validity of the design and the rapid recruitment of 100 broadly representative service users (Gossop et al, 1998). Their anonymous ratings may give a clearer understanding of their perspective than solicited feedback from a small number of individuals for 360-degree appraisal or a suggestions box. The results provided valuable positive feedback to staff, and were useful for discussion of the overall direction of the service, indicating areas that need improvement.
Most patients wanted to express their views about service improvement, but the failure to identify any patient who was willing to take any more active part in service planning is disappointing. This seems to be a recognised limitation of such an exercise (Coulter, 2002).
In response to the findings the Specialist Community Addiction Services are developing a range of information leaflets. This is one of the key policies recommended by the National Treatment Agency (2002). The desirability of changes to the de¤ cor of waiting areas and consulting rooms has been fed through to relevant management groups. Reducing waiting times and making the waiting and consulting rooms welcoming play a big part in engaging the patient in treatment.