Soc. Sci. Med. Vol. 47, No. 9, pp.

1351±1359, 1998
# 1998 Elsevier Science Ltd. All rights reserved
PII: S0277-9536(98)00213-5 Printed in Great Britain
0277-9536/98 $19.00 + 0.00

THE MEANING OF PATIENT SATISFACTION: AN

EXPLANATION OF HIGH REPORTED LEVELS
BRIAN WILLIAMS,1* JOANNE COYLE2 and DAVID HEALY3
1
Department of Epidemiology and Public Health, Ninewells Hospital and Medical School, Dundee
DD1 9SY, U.K., 2Department of Management and Social Sciences, Queen Margaret College,
Edinburgh, U.K. and 3Department of Psychological Medicine, Hergest Unit, Ysbyty Gwynedd, Bangor,
Gwynedd, U.K.

AbstractÐThe social policy background to the proliferation of patient satisfaction surveys is a desire
for increased patient representation and participation. Within this context, it is assumed that satisfac-
tion surveys embody patients' evaluations of services. However, as most surveys report high satisfaction
levels, the interpretation of satisfaction as the outcome of an active evaluation has been called into
question. The aim of this study is to identify whether and how service users evaluate services. This was
made possible through unstructured in-depth interviews with users of mental health services and
through more structured discussion around their responses on a patient satisfaction questionnaire (CSQ
18B) whose psychometric properties has been well documented. Twenty-nine people with current or
recent contact with mental health services within the British National Health Service were interviewed.
The data revealed that service users frequently described their experiences in positive or negative terms.
However, the process by which these experiences were transformed into ``evaluations'' of the service
was complex. Consequently, many expressions of ``satisfaction'' on the CSQ 18B hid a variety of
reported negative experiences. An explanation for this lack of correspondence is outlined. # 1998 Else-
vier Science Ltd. All rights reserved

Key wordsÐpatient satisfaction, consumer satisfaction, lay evaluation, mental health

BACKGROUND fulness in generating change in health service pro-

Over the past ten years consumer satisfaction has
gained widespread recognition as a measure of
quality in many public sector services. This has
been particularly true in the British National
Health Service (NHS) since the publication of the
1983 NHS Management Inquiry's call for the col-
lation of user opinion (Department of Health, 1984)
and the general shift towards a more consumerist
ethos within public services (Bury, 1997).
The call for an acquisition of the ``experience and
perceptions'' of patients has subsequently developed
into a call for a people-centred service (Welsh
Oce, 1993) and public involvement in planning
(Department of Health, 1991). Thus the collation of
users' evaluations has involved a diverse array of
methodologies including in-depth interviews, focus-
discussion groups, panels, consultation of voluntary
groups, and analyses of complaints and surveys
(Welsh Oce, 1992). Nonetheless, although a var-
iety of methods are available ad hoc satisfaction
surveys continue to ¯ourish (Department of Health,
1998).
Despite their widespread use satisfaction surveys
have been frequently criticised on both theoretical
and methodological grounds; in addition their use-
*Author for correspondence.
1351
vision has also been questioned.
Locker and Dunt (1978) ®rst pointed to a lack of
any theoretical underpinning for the concept of
patient satisfaction and the methods used to collate
it. Fifteen years later the same criticism was still
being voiced (Fitzpatrick, 1993). While more atten-
tion has been paid to the relationship between ex-
pectations and satisfaction (Linder-Pelz, 1982a,b;
Joos et al., 1993; Thompson and Sunol, 1995) a
consensus is still lacking on the mechanisms which
produce expressions of ``satisfaction''. At the root
of these problems is the concept of ``satisfaction''
itself. The meaning of the concept has seldom been
explicitly de®ned and therefore the development of
tools to measure it have been highly problematic.
DeVaus (1986) has commented:
Concepts are simply tools which ful®l a useful shorthand
function: they are abstract summaries of a whole set of
behaviours, attitudes and characteristics which we see as
having something in common. Concepts do not have some
sort of independence existence ``out there''... it is for us to
®rst de®ne what we mean by the concept and then develop
indicators for the concept as it has been de®ned. By their
very nature de®nitions are neither true nor false: they are
only more useful or less useful. (DeVaus, 1986, p. 40)
``Satisfaction'' is either implicitly or explicitly
de®ned as an ``evaluation based on the ful®lment of
expectations'' (Williams, 1994). If this broad de®-
nition is taken, it is possible to examine whether the
1352 B. Williams et al.
instruments being used are valid or not (i.e. are
they measuring what they intended to measure viz.
patients' evaluations of services). There is now a
growing literature suggesting that, at best, most
tools are not validated (Avis et al., 1995;
Leimkuhler and Muller, 1996) and at worst many
expressions of satisfaction may not be evaluations
at all (Williams, 1994; Owens and Batchelor, 1996).
Research shows that there is little consistent
empirical evidence to support the assumption that
expressions of satisfaction result from the ful®lment
of expectations. In some situations, it is debatable
whether expectations exist at all (West, 1976). Even
when they do exist studies have thrown doubt on
whether it is their ful®lment persee that results in
satisfaction (Fitzpatrick and Hopkins, 1983;
Bramadat and Driedger, 1993). The expectations-
ful®lment model is logically inadequate because it
predicts that any experience which is congruent
with that expected will result in satisfaction and any
which di€ers will result in dissatisfaction. Some
research has shown that what is important to
patient's perception of satisfaction is not the con-
gruency between expectations and experience, but
whether or not the experience was better or worse
than expected (Driedger, 1991). Similarly, Linder-
Pelz (1982a) found that expectations prior to con-
sultations were the main determinant of subsequent
satisfaction irrespective of whether they were ful-
®lled. Consequently, the research suggests that ser-
vice changes may fail to have any impact on
satisfaction ratings unless the mechanisms underpin-
ning expressions of satisfaction are more clearly
understood.
Since the raison d'eÃtre for satisfaction surveys is
a desire for patient representation (Department of
Health, 1984; Williams, 1995) de®ning concepts and
validating measurement tools which accurately col-
late patients' evaluations is extremely important.
Whit®eld and Baker have recently commented:
Poor questionnaires act as a form of censorship imposed
on patients. They give misleading results, limit the oppor-
tunity of patients to express their concerns about di€erent
aspects of care, and can encourage professionals to believe
that patients are satis®ed when they are highly discon-
tented. (Whit®eld and Baker, 1992, p. 152)
The development of an instrument which can
accurately embody patients' evaluations must be
founded on an understanding of whether and how
they evaluate services. This should facilitate instru-
ment development and guide the interpretation of
results.
METHOD
The aim of this study was to determine whether
people in recent receipt of mental health services
actually evaluate those services, and if so, identify
what mechanisms are involved in the process.
The data are drawn from a wider study
(Williams, 1996) concerned with exploring the ex-
perience, beliefs and social position of individuals
seeking help from a community mental health team
(CMHT) in order to inform the development of a
more ``person-centred'' mental health service (Welsh
Oce, 1993; Williams and Grant, 1998). Patients'
views of the services they had received were an im-
portant element within this exploration.
The study was set within a rural region of North
Wales, U.K. The area is served by a multi-disciplin-
ary community mental health team. Local general
practitioners refer clients on to the team who decide
which team member is most appropriate to deal
with the individual.
The theoretical stance underlying the study is a
perspective which regards people as social actors
who interpret stimuli and strive to make sense of
experience. Individuals construct the social world in
which they live and through these make sense of it
and interpret it; such constructions can be seen as
self-sustaining and self-renewing (Guba and
Lincoln, 1989). Thus in order to understand the
process underpinning expressions of satisfaction,
the research needed to explore actor's constructions
and de®nitions of situations.
Interviewees and theoretical sampling
Fifteen new referrals to a CMHT with no known
history of mental health problems were interviewed
prior to a ®rst appointment and again within two
weeks after the appointment Table 1. No other
exclusion criteria were used although none of those
interviewed presented psychotic symptoms or were
later given a diagnosis of psychosis. As interviews
were transcribed and analysed it became apparent
that some emerging issues required further, more
detailed examination. Consequently, other individ-
uals were sampled according to their likely ability
to cast light on these issues; this involved 5 non-ser-
vice users (i.e. with no mental health problems) and
8 clients who had ceased contact with the CMHT
within the previous eight months. A ``theoretical
sampling'' strategy and rationale was therefore
employed (Glaser, 1978; Strauss and Corbin, 1990).
Nature and location of interviews
Where possible interviews were carried out at
people's homes. It was hoped that this would set
clients at their ease and increase their sense of con-
trol over the nature and content of the conversa-
tion. It was also felt that interviews carried out in a
clinical setting might result in interviewees framing
their conversation in terms of a medical discourse
and only raise those issues believed to be relevant
in a clinical encounter. The researcher pointed out
that he had no medical quali®cations. An attempt
was made to avoid the interview taking the form of
a medical consultation and create a situation in
which a lay discourse could develop.
 The meaning of patient satisfaction
Table 1. Final number of interviews from theoretical sampling strategy
Pilot
interviews
No. of interviews per person 1 11  2 interviews, 1  3 interviews, 3  1 interviews
No. of people interviewed 6 15
Total number of people interviewed: 34.
Total number of interviews conducted: 47.
Since little is known of how and whether patients
evaluate services it was decided that each interview
with both current and recent service users should
consist of two parts. The ®rst section of the inter-
view consisted of an unstructured discussion of the
user's experience and their views of the service they
had received. The second section consisted of a
more structured discussion in which the intervie-
wee's responses on a patient satisfaction question-
naire (completed prior to the interview
commencing) formed the basis of the discussion.
The questionnaire was used simply as an extra tool
to facilitate in-depth discussion about each user's
views. It was hoped that the use of these two phases
of the interview would increase the ability of the
researcher to identify any evaluation processes
which might exist. While the evaluation process
which was ®nally identi®ed casts doubt on the val-
idity of the questionnaire it should be stressed that
the questionnaire was included only as a tool to fa-
cilitate discussion. The study did not set out to test
the validity of the questionnaire.
The patient satisfaction questionnaire used in this
study was the Client Satisfaction Questionnaire 18B
(CSQ 18B). The questionnaire is one of the few
instruments which has well established psychometric
properties (Tuan et al., 1984) and has been used
widely.
Interviews were relatively unstructured although
it soon became apparent that the most e€ective way
to proceed in initial interviews (i.e. prior to their
®rst consultation with the psychiatrist) was to ask
individuals to explain how they had arrived at their
current situation. This produced a narrative which
the researcher was able to document. Later in each
interview issues which had been raised by the indi-
vidual were examined in more detail by the inter-
viewer. This process meant that the patient had
almost free reign over the ®rst half of the interview
while the interviewer had predominant control over
the second half. This produced an overall discourse
in which the agenda was determined by the client
and then examined and explored by the interviewer.
In interviews after the appointment with a psy-
chiatrist had taken place clients were asked to com-
plete the CSQ-18B prior to a discussion of how
they felt the appointment had gone. Towards the
end of the interview discussion centred on the re-
sponses clients had made on the satisfaction ques-
tionnaire. The meanings of these responses were
explored in order to identify any underlying evalu-
ation process.
1353
People with past
New referrals to the CMHT Non-patients experience
1 1
5 8
Analysis
Analysis was in line with a grounded theory
approach. The process of data collection and analy-
sis formed a dynamic deductive±inductive cycle
(Strauss and Corbin, 1990). As data collection pro-
ceeded, the analysis was checked, compared and
revised, by returning to participants, exploring the
literature and theoretically sampling for new partici-
pants. Preliminary analysis informed the sampling
strategy and raised issues which were explored in
subsequent interviews. Second interviews (post
appointment) were used to check the validity of the
initial analysis by feeding back the interviewer's
understanding of the client's beliefs. Changes and
clari®cations were made where appropriate.
Transcription and analysis were aided by the use of
the Ethnograph computer program (Seidel et al.,
1988).
RESULTS
In order to examine whether, and if so, how
patients evaluate services, it was ®rst of all necess-
ary to de®ne the term ``evaluation''. The Oxford
English Dictionary de®nes ``evaluate'' as ``to ®nd or
state amount or value of...''. Consequently, an
``evaluation'' can be said to exist where a value is
attributed to an object, person or service. A state-
ment of value and an attribution to an object must
exist.
Interviews with current and recent clients were
heavily laden with descriptions couched in positive
or negative terms. Consider the following two com-
ments:
Andy: I've got to get this right see, because I'm not sitting
here trying to watch the telly, the wife crying and I'm sit-
ting here thinking ``Oh, my God, what's wrong with me.''
Why should I? I'm fed up with it. I'm not ill. I'm not de-
pressed, I'm crying because I've had enough of feeling this
way, you know... I'm just crying because I'm pissed o€
feeling this way.
Gillian: I was very upset actually by the way it (a letter
she had received from her psychiatrist) was worded, and
taught me a lot really Ð when you are writing a letter
you have to think who is reading it and I felt as though I
was being treated as a mental patient, perhaps who
wouldn't understand the letter.
In both these situations the clients described par-
ticular experiences negatively; the ®rst describes his
illness and the second a letter she had received.
Such descriptions (although relating to various
topics) were common throughout the study. If an
1354 B. Williams et al.
evaluation involves both a value and an attribution
to some object or person then it is clear that the
comments above both include ``evaluations''. In the
®rst comment the man attributes a negative value
to what he is experiencing (the mental health pro-
blem for which he is seeking help). In the second
example one might immediately assume that a nega-
tive value is being attributed to the letter; however,
this is not the case. The woman concerned is
describing her attitude and feelings towards the
letter and it is these which are described as negative,
and not the letter itself. It may be the case that this
woman also believed the letter to be of extremely
poor quality and would attribute a negative value
to it but this cannot be demonstrated from the data
given here.
Positive and negative descriptions always appear
to involve an attribution (the object of the descrip-
tion). Confusion arises, however, in knowing what
the description is being attributed to. In the ma-
jority of circumstances clients provided value
descriptions of their experiences of the service; how-
ever, these are not value descriptions (or therefore
``evaluations'') of the service itself. An explanation
for this is found if the concept and process of attri-
bution of value is explored in more detail.
Do service users evaluate services?
In moving from a description of a positive or
negative experience to a description of the service in
positive or negative terms (i.e. an evaluation of the
service) two concepts appeared to be involved.
These are:
The perception of the ``duty'' of a service or any
of its constituent parts or members.
The perception of the ``culpability'' of a service
or any of its constituent parts or members.
When service users believe that they are being
asked to evaluate a service their responses appear
to be guided by beliefs about what the service
``should'' and ``should not'' do (``duty'') and
whether or not the service is to ``blame'' if it does
things it shouldn't or fails to do things it should
(``culpability''). Consequently, there may be no
direct relationship between an individual's positively
or negatively described experiences and whether the
user evaluates the service positively or negatively.
Every experience of contact (e.g. each consultation)
with the service might be described negatively and
yet the person's evaluation of the service might still
be positive. ``Duty'' and ``culpability'' will be
explored in more detail by returning to the inter-
view data.
Perceived ``duty''. The concept of ``duty'' refers to
the service user's perception of what are and what
are not the roles and obligations of a service or any
of its constituent parts to the service user. The cor-
ollary of this is that ``duty'' represents the indivi-
dual's perceptions of his or her rights in relation to
the service. Consequently perceived ``duty'' can be
classi®ed as a speci®c type of expectation which rep-
resents not simply what individuals expect is likely
to happen but rather what should happen. This con-
cept falls between Freidson's concepts of ``practi-
cal'' (what is likely to happen) and ``ideal''
expectations (what the client would most prefer)
(Freidson, 1975).
The following woman had been feeling depressed
for some time and su€ered from agoraphobia. She
described going out of the house as extremely dis-
tressing and that it was therefore a major hurdle to
have to leave the house for her appointment with
the psychiatrist. Because of her agoraphobia she
would have preferred a home visit; however, she
did not request one because she did not perceive
this as a particular responsibility of the service. She
perceived the ``duty'' of the service in relatively
narrow terms: the removal or alleviation of her ex-
perience. In terms of the service's purpose she saw
her request for a home visit as trivial despite the
fact that it was important to her.
Int: You mentioned that you would rather have had a
home visit but you haven't mentioned it (to the sta€). Is
there any reason why you didn't?
Angela: Well, because everyone would probably think it
was so trivial. I know I think it's trivial to ask for a home
visit.
Int: It's quite important to you though, obviously. Because
you do sound as though you get quite worked up before
going out.
Angela: Yes, I do.
In this situation a negative experience (having to
leave the house for her appointment) cannot be
transformed into a negative evaluation of the ser-
vice. It was clear during the interview with the
above client that she did not regard the lack of a
home visit as a negative re¯ection on the service;
she would have liked one but this did not mean
that it was not doing its job properly. She did not
perceive a home visit as falling within the ``duty'' of
the service.
The duty of a community mental health team
would most commonly be thought of in terms of
the removal and/or alleviation of mental health pro-
blems. However, duty can also be seen at an inter-
personal level in that the behaviour of members of
a service may be subject to mundane norms and
rules. For example, it is still the duty of a psychia-
trist to be polite and not o€ensive to a service user
as the following comments illustrate.
Helen: He (the psychiatrist) was not as sympathetic as I
thought he would be after what I'd been through... He
was quite abrupt two or three times with me. Once es-
pecially when I didn't quite understand and... I mean he
should realise that I've gone through all these things and
I've come to see him at this late stage in my life... he must
realise that I'm feeling apprehensive.
I've been uncomfortable about being in this room (lack of
privacy) and therefore I'm not going to understand every-
thing clearly straight away and he suggested something to
 The meaning of patient satisfaction
me and I said ``Well, how would I do that?'' not meaning
you haven't told me and he said ``Well, if you let me I will
®nish'' and his hand movement and everything was quite
harsh and it just took me back a bit and I thought that's
not very nice.
While perceived duty may vary between users it
also depends on whether the duty being referred to
is that of the service as a whole or one of its con-
stituent parts. A client's perception of the duty (the
role and obligation to the client) of a receptionist
will di€er from the perceived duties of a psychia-
trist. This means that in the collation of users'
views of a service each question must be speci®c to
the aspect of the service being evaluated. Some
patient satisfaction studies have attempted to do
this, for example, Coyle et al. (1992) in a study of
users views of GP services devised questions which
related speci®cally to GPs, to practice nurses or to
receptionists. In the context of mental health ser-
vices, someone might be happy with the psychiatrist
but unhappy with the wider service. Although the
activity might fall outside of the realm of the psy-
chiatrist it may remain within the duty of the ser-
vice as a whole. The following comments from a
middle aged man demonstrates a distinction
between the duty of the psychiatrist and that of the
CPN.
George: He (the psychiatrist) is in medicine so he pre-
scribes Ð I don't think he's the one for listening to your
problems, I think he's the one that looks at you and
thinks right I'm giving you such and such a tablet. Not
motivating, getting you to build up your con®dence... the
CPN Ð group therapy.
Because of this man's perception of ``duty'' he is
unlikely to evaluate a psychiatrist negatively if he
does not spend a great deal of time listening to
him. Consequently, whether a negative experience
results in a negative evaluation of an aspect of a
service depends on the user's perceived allocation of
duty within that service.
Although the above examples portray duties as a
set of perceived obligations and user's rights, the
duty of a service or its constituents may best be
characterised as a continuum. In many instances
service users are unsure of the duties attributed to
various professionals or other aspects of the service.
Consequently, perceived duty varies along a conti-
nuum of certainty. This is apparent in the latter
quote; the patient is not only revealing a perception
of duty but, with reference to his own past experi-
ence, is actively attempting to discover what the
duties of psychiatrists and CPNs ``actually'' are.
Another example of the role of duty in evaluation
was demonstrated when one woman made reference
to ``standard government waiting time'' in her
assessment of the amount of time she had had to
wait for an appointment with a psychiatrist. It is
worth noting that this woman waited for three
months for an appointment.
1355
Diane: I'm saying that I did get an appointment, it was
within the standard government waiting time that you
expect for appointments... you've got to be realistic about
these things. The waiting turned out to be what you
would expect, so in that respect I don't think that I was
unfairly treated, I think, you know, how the system goes,
this is the best you can expect from the system. I've got
the best you can expect from the system.
Although she would clearly have liked to be seen
much quicker she believed that the service did not
fail in its duty and does not therefore evaluate it
negatively Ð she believes she was ``fairly treated''.
A negative experience did not lead to a negative
evaluation of the service.
This example highlights a central problem. In
order to develop more person-centred services infor-
mation on users' experiences of the service is
required. Do people have good or bad experiences
in relation to the service they receive? However,
many negative experiences may not be reported
because the user does not believe that the service or
a constituent part has failed in its ``duty'' (i.e. that
it should or should not have done something).
An example of this is the following man's experi-
ence. He had been depressed for the past two years
and had been seeing a psychiatrist throughout that
period. Despite the fact that he did not feel much
better he did not regard his psychiatrist in a nega-
tive manner. The comments below reveal that the
reason for this was that he did not regard ``curing''
as the duty of the psychiatrist. Rather, he saw it as
his own responsibility. This view re¯ects a culturally
sanctioned way of talking about illness. Studies
have found themes of self responsibility are particu-
larly strong in people's accounts of their chronic
conditions (Blaxter and Patterson, 1982; Robinson,
1990; Pollock, 1993). However, it is worth noting
that the notion of self responsibility is less promi-
nent in accounts of mental illness (Pollock, 1993).
This may be because with some mental health pro-
blems the concept of the self as autonomous and
self directing is more precarious. The metaphor of
®ghting or curing illness, may not feel appropriate
if the individual does not sense they have control
over their thoughts and actions. This was not how-
ever, the case with George (quoted below).
George: It doesn't matter what people say about psychia-
trists, they are there to help you, believe me, there is noth-
ing wrong with them. They are good people, which they
are in all fairness. They have a hard job to do, it is a hard
job and they can't cure you Ð I don't think they can
cure, they can help, but I don't think Ð the only person
that can cure you is yourself, really, but it's not as easy as
people make out.
Culpability. A further important ®lter through
which positive or negative experiences may ¯ow
before becoming evaluations of the service is the
``culpability'' of the service for a particular event or
non-event. Put simply, most individuals will not
evaluate a service negatively, even if it has produced
a negative experience (and failed in its duty), if
1356 B. Williams et al.
there are sucient mitigating circumstances for the
service failure. Conversely, lack of mitigating fac-
tors which might explain the practitioner's beha-
viour make a negative evaluation more likely. This
is evident in the following woman's report of her
®rst appointment with a psychiatrist.
Helen: It was last Wednesday. First I didn't see the con-
sultant; I saw a lady psychiatrist which threw me a little
bit because I was told I was seeing the consultant. I did
mind actually being seen by someone else because it just
meant another person knowing my business Ð my secrets.
Int: So you did mind being seen by someone else?
Helen: Yes I did mind... This woman just came Ð and
there was somebody else in the room where I was waiting
Ð and she called my name, my full name, which I minded
as well. I'm there to be seen by a psychiatrist and she's
calling me by my full name. I minded that. I did tell her
at the time. I said ``If ever we have to go through this
again can you not refer to me by my surname because I
do mind...
Int: So what was her reaction to that?
Helen:... She just said ``Why?'' I thought well, being a psy-
chiatrist I would have thought you would have under-
stood.
Helen's comments reveal the way in which the
service produced a negative experience for her,
through the psychiatrist's lack of regard for her
privacy. However, she goes further in implying that
this should not have happened. The doctor as a
psychiatrist should have understood issues of con®-
dentiality. Thus the client highlights the culpability
of the psychiatrist by pointing out that her status as
a psychiatrist left the practitioner with no mitigat-
ing factors which could explain her lack of sensi-
tivity for the privacy of the patient.
On the other hand, while people may feel that
the service has failed in its' duty, they may not hold
it responsible or evaluate it negatively, because they
accept that there are mitigating circumstances for
this. The following quote from a woman discussing
how she felt about the time she had to wait for an
appointment, illustrates this:
Int: How long did you have to wait?
Rose: I think it was about six weeks all in all.
Int: That's quite a long time isn't it after you've been feel-
ing down?
Rose: Yes, um, well obviously if Christmas hadn't been in
between it wouldn't have been that long.
Int: Were you surprised... when it took so long?
Rose: I was to begin with Ð Yes, but I thought perhaps
they've got a lot of other people that they need to see
®rst. I wasn't too pleased.
Here, a negative experience is described (she had
to wait six weeks while feeling very depressed).
However, culpability is not imputed to the service
since Christmas delayed things and she believed
there to be other more ``needy'' individuals. Yet,
despite this lack of culpability we have still discov-
ered that she would rather the service had managed
to see her quicker since she ``wasn't too pleased''.
The most commonly mitigated negative experi-
ence was the failure of the service to solve the
patient's mental health problem. Some clients
regarded ``curing'' as outside the duty of the service;
however, even for those who did regard it as the
service's responsibility any failure to cure was often
mitigated by a perception that if the sta€ can't cure
but are doing the best that they can, the failure is
not due to the sta€ or service but to current limits
in the knowledge of the cause and cure of mental
health problems. This is illustrated in the following
comments made by a woman with depression.
Helen: He (the psychiatrist) couldn't help me out, no.
Well, he did as much as he possibly could. He gave me
the tablets, he spoke to me nicely, explained everything he
could explain to me, he will get me in touch with a coun-
sellor. There's not a lot else he can do... I have to help
myself at the end of the day because it's my depression. I
know what's causing it. Part of it I know, and I've come
to the point where I can't rely on psychiatrists to help me,
I have to help myself.
Another man made similar comments.
Bernard: I've been seeing people for years now. I'm better
to some degree now but they've done their best for me so
I can't blame them, they've been great.
The relevance of ``duty'' and ``culpability'' for satis-
faction surveys
All interviewees reported some negative experi-
ences with regard to the service they had received.
However, in many instances responses to questions
on the satisfaction survey (which related to the
aspects of the service involved in these negative ex-
periences) tended still to be either ``satis®ed'' or
``very satis®ed''.
When the interviewer enquired about this discre-
pancy it became clear that the question on the sur-
vey form was being interpreted as it was intended
Ð an evaluation of the service provided.
Consequently, many of those negative experiences
which were explained in terms of being outside the
``duty'' of the service or for which the service could
be excused were not translated into expressions of
dissatisfaction.
On the survey form one man said that he was
``very satis®ed'' with the amount of help he had
received. His comments below, however, reveal that
this has absolutely nothing to do with the service
having done anything for him. Since he said he was
``very satis®ed'' it would be easy to infer that his
problems had been dealt with when in fact they had
not.
Int: How satis®ed are you with the amount of help you
received? You've put ``very satis®ed'' but in a sense they
haven't solved the problem.
Mike: No, but I do understand that that's down to me
really to solve the problem. There's no medication they
can give me...
 The meaning of patient satisfaction
This ``very satis®ed'' response is simply a re¯ec-
tion of the user's belief that the psychiatrist has a
valid excuse for not having solved his problem or
that it is outside the duty of the service. While this
may be interesting to note it does not help in the
monitoring and evaluation of the service. We need
to know whether the problem was addressed and/or
solved irrespective of the users' perception of duty
or culpability (or lack of it). The patient might have
been wrong in his perceptions and the failure to
solve the problem might have been due to the psy-
chiatrist's incompetence.
A similar situation occurred in relation to
another woman who had seen a psychiatrist and
had been referred elsewhere.
Int: (reading the questionnaire and answer) Overall, how
satis®ed are you with the services you have received? You
put ``Very Satis®ed''. That's despite the fact that they
haven't sorted you out.
Rose: Yes, because they are doing the best that they can
at the moment and hopefully sending me to the right
people.
Another woman, who eventually received a diag-
nosis of ``obsessive compulsive disorder'', initially
saw a junior doctor who she reported had done
nothing to help her. Nevertheless, the user said she
was ``very satis®ed'' with the doctor. The inter-
viewer asked the patient about this apparent contra-
diction.
Int: I'm surprised you said that you were very satis®ed
with this junior doctor you ®rst saw. From what you've
said so far she didn't do much for you?
Sally: Well, I think she had a cold at the time and was
feeling under the weather.
In this instance an ``acceptable'' mitigating factor
is apparent. Clearly, the expression of satisfaction is
not a re¯ection of the user's view of the service or
what it did for her, but rather a perception of culp-
ability and the boundaries of duty.
CONCLUSION
The interviews reported here demonstrate that
when asked to report their experiences of the men-
tal health services, users can provide detailed
descriptions of their experiences and attribute a
value to those experiences. It was argued earlier
that an underlying rationale for the collation of
users' views is the desire to develop more ``person-
centred'' services. The development of such surveys
requires ®rst and foremost access to the experiences
patients have and the meaning or value these have
for them.
This study has also highlighted that experiences
described by users in positive or negative terms do
not necessarily correlate with the user's evaluations
of the services which produced those experiences.
Consequently the process of moving from a report
1357
of a positive or negative experience to an evaluation
of the service is problematic.
Positive or negative experiences may only be cor-
related with positive or negative evaluations of ser-
vices when the concepts of duty and culpability are
taken into account. This gives rise to a process
where the link between positive and negative experi-
ences and actual reported evaluations of a service is
as shown in Fig. 1.
The above process may go some way to explain-
ing the continuously high levels of satisfaction
reported (Lebow, 1983) and the apparent discre-
pancy between these and the detailed criticisms of
medical encounters reported in qualitative studies
(Avis et al., 1997). Indeed Locker and Dunt (1978)
and Calnan (1988) comment that people are gener-
ally more critical of health services in qualitative
research. However, many of the ``criticisms''
reported in qualitative studies may actually be
reports of negative experiences and not, technically,
evaluations of the services at all. It is extremely
easy for the interviewer to assume that the former
is the latter until the patient is actually asked to
evaluate the service directly.
The concepts of ``duty'' and ``culpability'' have
been developed throughout this study and bear
some relationship to the concepts of ``expectations''
mentioned frequently, with little explication, in past
research papers. The nature of this relationship is
twofold. Firstly, ``perceived duty'' may be regarded
as a form of expectations which embodies an indivi-
dual's perception of what his or her rights are in re-
lation to the service, and what the service (or
component's) obligations are to him or her. This
di€ers from the previous dichotomy of ``practical''
and ``ideal'' expectations and suggests a more com-
plex process of evaluation than the dichotomy
allows for (Freidson, 1975).
Secondly, past research has highlighted the ¯uid-
ity of expectations and the ¯exibility by which they
are often characterised (West, 1976; Fitzpatrick and
Hopkins, 1983; Avis et al., 1997). Expectations are
seen as dependent on the context of the clinical
encounter and the past experience and knowledge
of the patient. The data provided in this study show
that expectations de®ned as rights (``duty'') may be
suspended or changed in situations where the
patient believes there are constraints on practitioner
behaviour or organisational practice. Thus by
accepting mitigating factors, users acknowledge that
the general and broad sets of expectations they hold
may become inappropriate when applied to a
speci®c and complex situation. The introduction of
the concept of ``culpability'' and its separation from
expectations in terms of ``duty'' may therefore help
to explain how and why expectations change and
are ¯exible.
The results of this study have consequences for
the usefulness of satisfaction surveys. If expressions
of satisfaction do consist of an attribution to the
1358 B. Williams et al.
Fig. 1. Tree diagram showing process links between experiences and expressions of dis/satisfaction.
service through the ®lters of perceived duty and
culpability then survey results must be interpreted
di€erently. High satisfaction ratings do not necess-
arily mean that patients have had good experiences
in relation to the service; rather, expressions of sat-
isfaction may more often re¯ect attitudes such as
``they are doing the best that they can'', or ``well,
it's not really their job to do...''.
If the underlying policy purpose of satisfaction
surveys is to provide patients with a voice in the
assessment and continuing development of services
then it is not adequate to utilise satisfaction survey
results. E€ort must be put into designing methods
of accessing patients' experiences of services and the
meaning and value they attach to them, whether
these are positive or negative and whether they can
be improved. Indeed, Cartwright (1983) reports a
number of surveys which include items focussing
the reported experiences and events and less on
respondents' evaluations of those events. These sen-
timents are in some ways re¯ected in the consulta-
tive document ``The New NHS'' (Department of
Health, 1998) which proposes an annual survey to
``enable the health service to measure itself against
the aspirations and experiences of patients...''
However, as McIver and Meredith (1998) point out
there is no ``o€-the-shelf'' questionnaire which can
satisfy the requirement to elicit patient views in all
service areas. Nonetheless, one fruitful approach
might be to extend further the government's con-
cern with improving speci®c aspects of the service
thought to be important to service users such as
waiting times, by identifying other issues of import-
ance especially in relation to illness-speci®c con-
texts. Thus studies in speci®c service areas may be
more appropriate than an all encompassing national
survey. However, understanding individual's experi-
ences of health services and how they interact with
their problems and aspirations is not an easy task,
and will require a more detailed understanding of
people's social circumstances and health beliefs.
Subsequent quality monitoring could then be di-
rected towards monitoring whether speci®c events
did or did not occur and, separately, accessing
users' descriptions of their experiences.
In such a quality monitoring activity patient ex-
pectations would have a reduced importance. In
e€ect they would be replaced by research into what
is and what is not important to patients. It is argu-
able that within a strict consumerist model client's
expectations cannot be ``wrong'' (Potter, 1988).
However, in the context of the provision of public
sector services consumer sovereignty frequently
breaks down (Shackley and Ryan, 1994); patients
are citizens as well as consumers (Clarke and
Stewart, 1985; Barnes and Prior, 1995). The pro-
vision of services to the individual will e€ect both
the community and other individuals.
Consequently, some individuals' expectations may
be inappropriate.
While the implication of this study's ®ndings for
current satisfaction surveys is substantial, a more
 The meaning of patient satisfaction
limited role may remain for them. High reported
satisfaction ratings cannot be taken to indicate that
patients have had or are having good experiences in
relation to a particular service. ``Dissatisfaction''
rates, however, may be of more use as an indication
of a minimum level of negative experience and may
therefore be of potential use in benchmarking exer-
cises.
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