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An “inverse satisfaction law”? Why don't older patients criticise health services?
  1. A Bowling
  1. Department of Primary Care and Population Sciences, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK

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    Health services across the developed world attract high satisfaction ratings from patients, regardless of levels of service effectiveness and equity of access. People aged 65 and over express higher levels of satisfaction with health services than younger adults, and they are much less likely than the latter to report difficulties in access to specialists. Such findings are consistent across different types of health systems, and regardless of whether surveys are sponsored by individual governments, private companies, independent research bodies, or collectively across countries by the Commonwealth Fund.

    The consistency with which high satisfaction ratings are obtained in patient satisfaction surveys explains why governments continue to sponsor them—using them to temper more uncomfortable, objective data (for example, on hospital waiting lists, mortality rates, five year survival rates). Patient satisfaction surveys have proliferated in the USA and UK, and are increasing across Europe, as indicators of the quality of health services. Oddly, governments are less reliant on satisfaction questionnaires in relation to education, employment, pensions, and other major policy areas, where objective process and outcome indicators carry more weight.

    The relative lack of criticism among older people is of particular concern. It is more perplexing given the results from our own qualitative and quantitative research, which shows that people aged 65 and over value their health more highly than younger people, and that they are quite aware that their mental and physical health is essential for continued social inclusion. Moreover, research evidence from the UK and USA shows that people aged 65 and over are more likely to be subject to delays in both treatment and specialist referrals, are more likely to then become severe, emergency cases, and at increased risk of complications and adverse events.

    Why are patients so reluctant to tick dissatisfied boxes in survey questionnaires when their health services are inadequate? In the case of people aged 65 and over, this reluctance may be partly historical. Older people have been reported to feel “lucky” in comparison with their parents—their parents had even less control over their health and health care. Similarly, they may feel “gratitude” because they have better access to a wider range of health technologies today. Uncritical attitudes might reflect the lack of confidence among older people in demanding services, reflecting, in turn, their lower levels of education than younger adults. Hence they might also be less aware of potentially beneficial treatments. There is some evidence from surveys that people value themselves less with increasing older age, and feel they should be prepared to give up their place in health service queues to younger people. Perhaps they feel morally obliged, “on the surface”, to agree with this “fair innings” principle. But are they really “satisfied” to watch their health deteriorate when denied appropriate health care?

    Researchers must take responsibility for failing to detect more critical attitudes. Satisfaction questions are often general in focus, but researchers are well aware that more specific, as well as open-ended and in depth, questioning, can yield higher levels of criticism about health services. The implications of this for public health is that there is a need to avoid complacency in the provision of health services, in particular for older people, and a need for governments to stop partly defending inadequate service provision with reference to high patient satisfaction levels. Equity issues in older age have been relatively neglected; it is now time to tackle these. Our approach to aging and issues of equity will mark how we, with our increasing expectations, will be treated in the future.