Dr Ayman Shenouda
Patient loyalty and trust
It’s hard to pinpoint precisely what inspires long-term patient loyalty.
Quality of care and trust must come into it. The ability to listen, having a caring presence and reliability would also factor highly.
From my own experience, I think patient loyalty is mostly about trust. And it is timely and effective communication that builds that trust.
Of course, for doctors, communication also involves giving the patient bad news. Listening actively and providing comfort being core communication skills.
There are very few studies that have explored those factors seen to build and maintain a patient’s loyalty towards their GP or a practice.
Some recent research in France provides some specific insights while a more recent study closer to home provides a new novel way to measure both GP and practice loyalty.
The loyalty equation
First, let’s look at a possible loyalty equation. A 2016 French study tested aspects of patient loyalty in the general practice context.
This study found that loyalty was more complex than commonly assumed and is reliant on a few factors. It involves dimensions of trust, listening, quality of care, availability, and familiarity.
So, the loyalty equation from this study looks like this:
Trust + Listening + Quality of Care + Availability + Familiarly = Patient Loyalty
This is interesting enough but I think what makes this study really interesting is that the loyalty factor was seen as important enough to formalise it in policy.
The efficiency factor to loyalty
In France, the Caisse d’Assurance Maladie (public health insurance fund) recognises a coherence in maintaining the doctor-patient relationship in terms of efficiency and healthcare costs.
This has been formalised in law since 2004 and was part of broader reforms to health insurance which requires a ‘preferred doctor declaration’.
The policy requires adult patients who want optimal coverage of their care by national health insurance to choose a preferred doctor - typically a general practitioner. 
What we see in France is the use of a single lever-regulation through what it calls its ‘gatekeeping’ reform.
The carrot and stick approach of this effectively means that every adult must first choose a primary doctor, or médecin traitant, or risk higher healthcare fees and being reimbursed at a lower rate.
The policy aim is to control both the demand and supply side of health care provision to improve care coordination and reduce utilisation of specialists’ services.
The policy operates by encouraging patients to choose one GP and imposes financial sanctions if they don’t. This gives value to the relationship and makes the patient’s loyalty official.
One evaluation of this reform explored effect and found that specialist visits fell slightly while self-referred visits and the number of different GPs seen also declined.
In other words – policy success – but does a forced scheme generate patient loyalty?
What can we learn from the French experiment?
Forced schemes like this are never good policy. But while this scheme is perhaps set out to control access to specialists the positives will be seen over time through continuity of care.
The French patient loyalty study actually found this to be true. That, by inciting patients to always consult the same doctor, the reform of the preferred doctor scheme reinforced that bond.
Patient loyalty in the Australian policy context has resulted through a stronger policy framework which enables choice. So, where are we at in terms of policy success against the loyalty factor?
The Australian context
The richness and potential of de-identified Medicare data were shown through a recent Australian study led by the Centre for Big Data Research in Health, UNSW, and published this month in the MJA. 
This study is said to open up a new toolbox for exploring how patients use healthcare services. It’s the innovative approach using network analysis that makes this a standout.
It uses network analysis of big data analysing millions of Medicare claims to gain insights into the organisation and characteristics of Australian general practice over a 20-year period.
New ways to measure loyalty
Providing a novel way to measure change in Australian general practice over two decades, the study shows that while there has been a move towards bigger GP practices, patient loyalty remains high.
These results were found by looking at the claims to see when patients were visiting different doctors for their GP services.
By applying a network analysis approach, it showed where doctors had many patients in common that they were likely to be sharing the care for these patients in the same practice.
These were grouped as a provider-practice community or PPC which also provided new insights into patient loyalty.
The results showed that patients’ loyalty to their usual GP and usual GP practice is high and has been stable over the last 20 years.
The loyalty result is exciting combined with the innovative approach used in this study to find that the density of patient sharing within a PPC correlated with patient loyalty.
The fact that patients see multiple GPs within a practice is also significant in terms of practice design and enabling more team-based GP care models.
The further link made in this study in terms of supporting future program design in terms of where to target incentives for encouraging quality primary care is also good news for our practices.
For good policy reach, program success relies in part on the patients’ choice of practice and this fact is now more keenly linked to that loyalty factor as a result of this study.
Australian success story
These results provide a really positive outlook on Australian general practice and our approach to healthcare policy in enabling equity in access.
In contrast to the French policy experience whereby a forced scheme has formalised patient loyalty in a way, the Australian experience shows that patient loyalty and choice of practice comes through less forced means.
It will be interesting to see what more can be explored through big data analytics and the network analysis approach used in this study to better understand our health system.
 Gérard L, François M, de Chefdebien M, Saint-Lary O, Jami A. The patient, the doctor, and the patient’s loyalty: A qualitative study in French general practice. Br J Gen Pract 10 October 2016; bjgpnov-2016-66-652-gerard-fl-p. DOI: https://doi.org/10.3399/bjgp16X687541 Available at http://bjgp.org/content/early/2016/10/10/bjgp16X687541#ref-9
 Law No. 2004-810 of 13 August 2004 concerning health insurance. Article 7. Published in JORF n°190 2004–08–17: 14598. [In French]. Legifrance Paris, 2015.
 Le Fur P, Yilmaz E. (2008) Referral to specialist consultations in France in 2006 and changes since the 2004 Health Insurance reform. 2004 and 2006 Health, Health Care and Insurance surveys. Questions d’Économie de la Santé 134:http://www.irdes.fr/EspaceAnglais/Publications/IrdesPublications/QES134.pdf
 Gerard 2016 Op. cit.
 Dumontet M, Buchmueller T, Dourgnon P, Jusot F, Wittwer J. Original research article. Gatekeeping and the utilization of physician services in France: Evidence on the Médecin traitant reform. ScienceDirect Health Policy Volume121,Issue6,June2017,Pages675-682.Availableat: https://www.sciencedirect.com/science/article/pii/S016885101730115X
 Gerard 2016 Op. cit.
 Tran B, Straka P, O Falster M, Douglas KA, Britz T, Jorm LR. Research. Overcoming the data drought: exploring general practice in Australia by network analysis of big data. MJA 209 (2) j 16 July 2018. Pages 68-73. Available at:
Dr Ayman Shenouda