Consumer satisfaction of patients attending psychiatry of learning disabilities clinics

A consumer satisfaction survey of patients with learning disabilities and mental health needs attending out patient psychiatry clinics was performed using a questionnaire administered by their carer. Sixty completed questionnaires were returned and the results were analysed to determine whether demographic or service variables were correlated with the degree of satisfaction. Younger patients living independently or with their family and those who were not prescribed psychotropic medication were more satisfied. The service variables associated with increased satisfaction were comfortable waiting areas, punctuality and good communication with the doctors. Following there number patients with both learning disabilities (LD)and mental health (MHN)living in

Following the hospital closure programmes in the South East Thames region there are now a large number of patients with both learning disabilities (LD) and mental health needs (MHN) living in the community. Their psychiatric treatment occurs more frequently in out-patient settings, which improves the use of clinicians' time; also, such services may be integrated with parallel generic psychiatry resources.
People with LD should expect to have access to quality services and thus it is useful to evaluate their perception of the service provided as part of quality assurance. Recent White Papers have favoured actively seeking 'consumer' opinion as a means of improving the quality of services as consumers are no longer considered to be passive users (Gravestock, 1994). While others have explored the views of carers using LD services (Hall & Pieri, 1992), there has been no recent research on consumer satisfaction of adults with LD and MHN attending local psychiatric out patient departments. This is in spite of the increasing recognition of their mental health and social care needs by specialist community psychiatry services (Bouras & Drummond, 1992).
The difficulties in interviewing people with LD include acquiescence, poor response to open questions, suggestibility and communication problems (Atkinson, 1988). The challenge re mains for service researchers to involve these patients effectively so that they can express their viewpoint accurately.

The study
The aim of the study was to relate measured dimensions of consumer satisfaction with patient and service variables. The study questionnaire was devised to incorporate patient demographic and clinical data, coded to maintain anonymity. It included seven yes/no items and nine semantic differentia] questions. After each clinic appoint ment patients were asked if they would complete a questionnaire with their carer administering questions and recording their responses.
The study included all patients seen in three adult psychiatry of LD clinics serving the inner-London boroughs of Lewisham and Southwark who agreed to participate during the five-month study period. The data from the patients who had severe LD were excluded from the statistical analysis because their poor verbal comprehen sion and expressive skills made it unlikely that the responses recorded were a reliable and valid representation of their own views, but rather were to be those of their carers. No patients with a profound LD were seen in the clinic.
The responses to the yes/no questions were scored on a 0-2 scale with 0=no reply, 1 = dis satisfied and 2 = satisfied. The response to the semantic differential questions were scored on a 0-4 scale with 0=no reply, l=very dissatisfied, 2=dissatisfied, 3=satisfied and 4=very satisfied. Results were coded and scored according to the level of satisfaction expressed for each item.

Demographic and clinical data
Sixty-five questionnaires were returned (response rate 73.0%). Data from five patients were ex cluded as they had a severe learning disability, giving a response rate of 71.4% (27 (45%) male, 33 (55%) female) for further analysis.

Satisfaction scores
The mean satisfaction score was 35.3 (range 27-42; s.d. 3.2). The satisfaction score of 35 was used to divide the sample into two groups, i.e. higher satisfaction was > 35 and lower satisfaction was <35. These two patient groups were compared using chi-squared tests (with Yates correction if indicated) to check for statistical differences in demographic, clinical, as well as service delivery variables.
Concerning patient demographic and clinical variables, the only statistically significant find ings were: patients expressed greater satisfaction with their clinic attendance if living at home or independently compared with living in supported residence (x2= 4.53. d.f.= l. P<0.05); attended clinics with a family member rather than a support worker (x2= 4.53, d.f. = 1, P<0.05); and if they were not receiving psychotropic medication (X2= 5.14, d.f. = 1,P<0.05).
The service delivery variables are listed in Table 1.

Comments
The survey population was broadly representative of the patients attending local psychiatry of LD clinics in that the majority lived in supported community residences and attended for assess ment and treatment of psychiatric illness. How ever, although patients with all levels of LD attend the clinics, data from those with severe disability had to be excluded from this study as discussed above.
The questionnaire used was agreed by collea gues to have face validity but due to changing service and patient variables it proved practically impossible to assess the test/re-test reliability. Therefore the results of this empirical survey should be considered suggestive rather than definitive. Whether patients had borderline, mild or moderate LD or different levels of communica tion ability did not appear to influence their capacity to express high or low satisfaction and there was little evidence of acquiescence in their responses. Suggestibility and social desirability effects cannot be excluded, given the limited responses of many patients to the open questions (Atkinson, 1988).
The analysis of patient variables suggested that the younger patient group was more satisfied with the clinics. This may be because they were less likely to have spent several years living in hospital and were therefore more accustomed to attending clinics and GP surgeries for their health care.
Patients who lived independently or with their family, and attended with a family member expressed more satisfaction. Reasons for this difference may include a genuine appreciation of the community-based services which aim to maintain people in community settings or con versely the patients in supported residences are enabled by their support workers to express more general and specific dissatisfaction. Thus, future similar studies also comparing the views of patients with those of their carers would be useful.
Patients who were not receiving medication generally scored greater levels of satisfaction. Those receiving medication may be less compliant or have less insight into the reasons for their medication and their psychiatric morbidity could be affecting their perception of the service.
It was reassuring to find that 95% of clinic attenders found the clinic times convenient and 98.3% were given sufficient notice of the appoint ment. Of the service delivery variables signifi cantly associated with increased satisfaction, the finding on how good the doctor was at listening and understanding problems was particularly significant. This is a strong indication that good doctor-patient communication is vital to consu mer satisfaction in psychiatry of LD clinics as in other clinics. Several of these findings support those of similar studies (Sheikh & Meakin, 1990) and as expected, this study showed that those who scored higher levels of satisfaction generally felt better after their attendance.
The survey proved useful in assessing the patient and service variables associated with the consumer satisfaction of adults with mild and moderate LD. We hope that similar studies could research the satisfaction of other groups of people with LD such as those with epilepsy and physical disabilities. However, different methods will be required in order to assess adequately the views of children and adults with more severe LD. Consumer satisfaction of patients attending psychiatry of learning disabilities clinics