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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLORADO Civil Action No.
SECURITIES AND EXCHANGE COMMISSION, Plaintiff,
SEALIFE CORPORATION, ROBERT E. MCCASLIN, ROLAND M. THOMAS, ERT TECHNOLOGY CORPORATION, DOUGLAS A. GLASER, BARRY S. GRIFFIN, JEFFREY A. HAYDEN, MORGAN J. WILBUR 111, Defendants.
Plaintiff, Securities and Exchange Commission, alleges as follows for its complaint:
From about December 2002 through at least August 2003, SeaLife Corporation,
Robert C. McCaslin, Roland M. Thomas, ERT Technology Corporation, Douglas A. Glaser, Barry S. Griffin, Jeffrey A. Hayden, and Morgan J. Wilbur I11 engaged in a scheme that defrauded the investing public by using materially false and misleading public statements and nianipulative stock trading to create an artificial market for, and to sell, stock in SeaLife Corporation without registration or a valid exemption under the federal securities laws.
SeaLife, McCaslin, ERT, and Thomas drafted and caused to be disseminated
materially false and misleading public statements regarding SeaLife to create artificial market demand for SeaLife's stock and to facilitate a distribution of SeaLife stock to the public.
Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur each engaged in
manipulative stock trading in SeaLife stock during the distribution to create an artificial market for the stock, to falsely create the appearance of volume, and to fraudulently interfere with the true supply and denland for the stock. 4. The Defendants caused SeaLife stock to be sold in transactions without
registration or valid exemption under the federal securities laws. 5. After it began trading in early 2003, the price of SeaLife stock reached as high as
$5 per share and fluctuated between $.60 and $2 per share during most of the period that the Defendants engaged in the scheme. As the scheme began to unravel and the Defendants no longer artificially supported the price of SeaLife stock, the stock price declined below $.40 per share where it traded most of the remainder of 2003. However, Defendants continued to distribute SeaLife stock throughout 2003. 6. As a result of the scheme, the Defendants received SeaLife stock proceeds as
follows: Hayden received approximately $633,301 in proceeds; Glaser received approximately $l61,in proceeds; Thomas and ERT received approximately $158,778 in proceeds; Wilbur received approximately $62,928 in proceeds; and Griffin received approximately $5 1,545 in proceeds.
JURISDICTION AND VENUE
The SEC brings this action pursuant to authority conferred on it by Section 20(b)
of the Securities Act of 1933 [15 1J.S.C. 5 77t(b)] and Sections 21(d) and 21(e) of the Securities Exchange Act of 1934 [15 1J.S.C. $$ 78u(d) and 78u(e)]. 8. This Court has jurisdiction over this action pursuant to Section 22(a) of the
Securities Act [ I S U.S.C.
and Section 27 of the Exchange Act [15 U.S.C.
Venue lies in this Court pursuant to Securities Act Section 22(a) and Exchange Act Section 27 [15 U.S.C. $5 77v(a) and 78aal. 9. In connection with the transactions, acts, practices, and courses of business
described in this Complaint, the Defendants, directly or indirectly, have made use of the means or instnunentalities of interstate commerce, of the mails, andlor means and instnunents of transportation or communication in interstate commence. 10. Certain of the transactions, acts, practices, and courses of business constituting the
violations of law alleged herein occurred within the District of Colorado. Moreover, Glaser, Griffin, and Hayden reside within this district.
SUMMARY O F VIOLATIONS
SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur
violated the securities registration and antifraud provisions of the federal securities laws: Sections 5(a), 5(c), and 17(a) of the Securities Act [15 U.S.C.
$5 77e(a), 77e(c), and 77q(a)]; and 5
Section 10(b) of the Exchange Act 115 U.S.C. $ 78j(b)], and Rule 1Ob-5 thereunder [17 C.F.R. 240.10b-51; and unless restrained and enjoined will violate such provisions in the future.
Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur violated Rule 101 of
Regulation M [17 C.F.R. provision in the future. 13.
242.1011, and unless restrained and enjoined will violate that
McCaslin, Thomas, ERT, and Glaser violated Sections l3(d)(l) and 16(a) of the
Exchange Act [IS 1J.S.C. C.F.R.
$5 78m(d)(l) and 78p(a)] and Rules
13d-1 and 16a-3 thereunder 117
240.13d-1 and 240.16a-31, and defendants Thomas, ERT, and Glaser violated
Section 13(d)(2) of the Exchange Act [15 U.S.C. 5 78m(d)(2)] and Rule 13d-2 thereunder [17 C.F.R. $ 240.13d-21, and unless restrained and enjoined will violate such provisions in the future. 14. SeaLife, aided and abetted by McCaslin, violated Section 13(a) of the Exchange
Act [IS U.S.C. $ 78m(a)] and Rules 13a-11, 13a-13, and 12b-20 thereunder [17 C.F.R.
240.13a-11, 13a-13, and 12b-201, and unless restrained and enjoined will violate or aid and abet violations of such provisions in the future.
SeaLife Corporation, a Delaware corporation based in Culver City, California,
was formed through a 2002 merger between a closely-held Nevada corporation, also called SeaLife Corporation, and a public shell company named Integrated Enterprises, Inc. Immediately after the merger between these two entities, the resulting public company changed its name to SeaLife Corporation. SeaLife is in the business of manufacturing and selling boat paint and several other products. It is a reporting company pursuant to Section 12(g) of the Exchange Act. SeaLife stock traded under the symbol "SL,IFmon the Over-The-Counter Bulletin Board, a regulated stock quotation service. At relevant times, SeaLife traded at prices under $5 per share and was a penny stock.
Robert E. McCaslin, age 53, is a resident of Marina Del Rey, California.
McCaslin is the president and co-founder of SeaLife. 17. Roland M. Thomas, age 55, is a British citizen who resides in Las Vegas,
Nevada. Thomas is a business consultant and stock promoter who helps take small companies public. Thomas purportedly provided consulting services at times through his company, ERT Technology Corporation.
ERT Technology Corporation is a Delaware corporation wholly-owned by
Thomas. 19. Douglas A. Glaser, age 34, is a resident of Denver, Colorado. Glaser is a
business consultant and stock promoter. He has held securities licenses, but in April 1997, Glaser was barred from association with any broker or dealer by the SEC after an administrative proceeding. 20. Barry S. Griffin, age 39, is a resident of Denver, Colorado. Griffin worked as
an automobile salesman. 21. Jeffrey A. Hayden, age 59, is a resident of Walden, Colorado. Hayden has held
securities licenses, but has not been associated with a broker-dealer or other SEC-registered entity since 1997. 22. Morgan J. Wilbur, 111, age 59, is a resident of Savannah, Georgia. Wilbur is a
business consultant who offers financial services to small companies. He has held securities licenses, but has not been associated with a broker-dealer or other SEC-registered entity since 2000.
SEALIFE BECAME PUBLICLY TRADED AND ISSUED STOCK TO THOMAS, AN ERT EMPLOYEE, AND GLASER TO SELL TO THE PUBLIC
23. During 2002, McCaslin became interested in raising capital for SeaLife
Corporation, the private predecessor company to Sea1,ife. McCaslin met Thomas, who agreed to help the company raise capital by generating market interest for the company's stock once it became publicly traded on the securities markets and by selling the stock to the public. Thomas agreed to perform these services in exclzange for "free-trading" stock. 24. In early November 2002, Thomas met Glaser and received a proposal from
Glaser for developing a trading market for SeaLife Corporation stock after the company became
publicly trading on the securities markets. Among other things, Glaser told Thomas that he could arrange for market makers, facilitate nlinimurn trading volume and bid price, and arrange financing. Glaser proposed that one million shares be made available to execute the plan. 25. During November and December 2002, the private company SeaLife Corporation
entered negotiations to merge with Integrated Enterprises i11 order to become a publicly-trading company. At the time, Integrated Enterprises was a Delaware shell corporation whose stock was publicly trading on the Over-The-Counter Bulletin Board. SeaLife Corporation agreed to pay the controlling shareholders of Integrated Enterprises $400,000 to complete the merger and become a publicly-trading company. Because SeaLife Corporation did not have enough cash, it
promised to pay the controlling shareholders of Integrated Enterprises tlze $400,000 in the future. On or about December 20, 2002, the private SeaLife Corporation merged with Integrated Enterprises and the resulting publicly-trading company became SeaLife Corporation. To
provide security for the $400,000 payment, the controlling shareholders of Integrated Enterprises retained 2 million shares of preferred stock that was convertible into enough common stock to
regain control of SeaLife in the event of nonpayment. After the merger, McCaslin was president and director of SeaLife. 26. In December 2002, pursuant to their prior discussions, Thomas and ERT signed a
written agreement with Glaser outlining a plan to distribute SeaLife stock to the public. Pursuant to the agreement, Glaser agreed to sell at least $750,000 worth of SeaLife stock to the public and then use the proceeds to pay $200,000 to the former controlling shareholders of Integrated Enterprises as a first installment on the $400,000 owed to them, pay $400,000 to SeaLife for its capital needs, and split the remaining proceeds with Thomas and ERT. Glaser also agreed to establish a healthy stock position, active market ~nakers,and volume trading in SeaLife stock. According to the agreement, SeaLife issued one million shares on January 2, 2003, as follows: S00,000 shares to Thomas; 300,000 shares to Glaser; and 200,000 shares to an enlployee of ERT. 27. As a result of the stock issued by SeaL,ife in December 2002 relating to the
merger and early January 2003 relating to the written agreement between Thomas and Glaser, McCaslin owned over 30% of SeaLife's outstanding cornrnon stock, and Thomas, Glaser, and ERT's employee as a group owned 12.5% of the company's outstanding coinrnon stock. McCaslin filed Exchange Act ownership reports on Form 3 and Schedule 13G concerning his three million shares on September 10, 2003, nearly nine months after the stock was issued and only after learning of the SEC investigation. Thomas, ERT, and Glaser never filed any Exchange Act ownership reports with the SEC.
SEALIFE, MCCASLIN, THOMAS, AND ERT DISSEMINATED MATERIALLY FALSE INFORMATION T O THE PIJBLIC 28. In order to create market demand for, and to sell SeaLife stock, SeaLife,
McCaslin, Thomas, and ERT drafted and disseminated materially false information to the
investing public via the Internet, press releases, public filings with the SEC, and information given to investors. At no time did SeaLife issue a comprehensive prospectus or disclosure document describing all material factors concerning the company's stock. The material false information accompanied the nlanipulative stock trading of Thomas, ERT, Glaser, Hayden, Griffin, and Wilbur and aided the Defendants' stock distribution efforts. The Defendants engaged in special efforts to distribute SeaLife stock by issuing the press releases, public statements, and other information to generate market demand for the stock. 29. In late December 2002, SeaLife, McCaslin, Thomas, and ERT authored a
"Corporate Fact Sheet" and a "Business Plan" for SeaLife which were posted on SeaLife's Internet web site. SeaLife also distributed the Fact Sheet and Business Plan in information packets to potential investors. Both the Corporate Fact Sheet and Business Plan were materially false and misleading for the following reasons, among others: a) The Fact Sheet and Business Plan falsely stated that SeaLife's research, development, and production procedures were complete, allowing the company to focus its resources on marketing and sales, when in fact additional product testing and capital were required. b) The Fact Sheet and Business Plan falsely stated that SeaLife's intellectual property, trade secrets, and proprietary products were worth more than $60 million, when in fact SeaLife's internal undisclosed financial statements valued the same assets at less than $1.5 million. c) The Fact Sheet and Business Plan contained projections that SeaLife would make over $5 million in sales during its first year, and that it would generate large profits from these sales because it had a 70% gross sales margin. SeaLife did not
have sufficient sales to make any claims about its margin and the projections were false and misleading because they lacked disclosure that SeaLife needed to perform more product testing and raise more capital and because SeaLife did not disclose any historical or current financial infonnation with the projections. d) The Fact Sheet and Business Plan failed to disclose that SeaLife and McCaslin had retained Thomas and Glaser as its agents to sell SeaLife stock to raise capital and to pay off the $400,000 that was owed to the former controlling shareholders of Integrated Enterprises for the price of merging with their shell company. The documents also failed to disclose that those former controlling shareholders of Integrated Enterprises could regain control of SeaLife if the $400,000 was not paid to them by converting their preferred stock. 30. In order to create market denland and to sell SeaLife stock, SeaLife, McCaslin,
SeaLife reported the settlement in an August 7, 2003, press release falsely stating
that SeaLife management learned of the existence of the preferred stock in July 2003. In fact,
the existence of the prefened stock was disclosed to McCaslin in connection with the merger negotiations with Integrated Enterprises in or before December 2002. Moreover, the preferred stock was reported in Integrated Enterprises' public filings, which were available to SeaLife management at the time of the reverse merger. C. THOMAS, ERT, GLASER, HAYDEN, GRIFFIN AND WILBUR MANIPULATED THE PRICE O F SEALIFE STOCK DIJRING THE PUBLIC DISTRIBUTION 36. Beginning about January 2, 2003 and continuing through March 2003, Thomas,
ERT, Glaser, Hayden, Griffin, and Wilbur worked together to nxinipulate the price of SeaLife stock by engaging in stock trading designed to create an artificial market for the stock, the appearance of volurne, and to interfere with the true supply and demand for the stock. The Defendants' manipulative stock trading occurred while distributing SeaLife stock to the public and was aided by the material false and misleading information disseminated by SeaLife, McCaslin, ERT, and Thomas. 37. The Defendants caused manipulative stock trading in SeaLife stock through
brokerage accounts under their control. a) Thomas controlled t h e e accounts in the name of ERT, one at Spencer Edwards, Inc., a brokerage finn in Denver, Colorado, another at GunnAllen Financial, a brokerage finn in Tampa, Florida, and the third at Fordharn Financial Management, Inc., a brokerage finn in New York, New York. b) Glaser controlled two accounts in his name at Spencer Edwards and one account in his name at GumAllen. c) Hayden controlled accounts in the names of Diamond Key Corporation, Ladan Reserve Inc., and Io James at J. Alexander Securities, a brokerage firnl in Los Angeles, California. Hayden also controlled two accounts at Research Capital
Corporation, a brokerage firm in Vancouver, Canada, one account in his name and the other in the name of Sandwood Investments S.A. Griffin controlled an account in his name at BMA Securities, Inc., a brokerage firni in Rolling Hills Estates, California. Wilbur controlled four accounts in his name, one at Spencer Edwards, another at GunnAllen, a third at Fordham Financial, and a fourth at Raymond James & Associates, a brokerage firm in Ocala, Florida. After receiving stock from SeaLife, Thomas and Glaser followed a pattern of selling large share blocks under their control to Griffin, Hayden, and Wilbur, who then sold the stock into the market. W i l e the distribution was occurring, in order to create artificial volume and fraudulently support the stock price, Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur bought SeaLife stock in the market. For example, between January 9 and March 3 1, 2003, the Defendants made numerous purchases of SeaLife stock in the market as follows: a) Thomas, through ERT, caused or made 13 stock purchases totaling 20,700 shares. b) Glaser caused or made 13 stock purchases totaling 66,160 shares. c) Griffin caused or made 28 purchases totaling 47,700 shares. d) Hayden caused or made 72 purchases totaling 107,200 shares. e) Wilbur caused or made purchases totaling 50,900 shares.
In January 2003, Glaser caused 200,000 shares of SeaLife stock to be transferred
to two nominee entities under the control of Hayden, 100,000 shares to Diamond Key Corporation and 100,000 shares to Ladan Reserve, Inc. Hayden deposited the 200,000 shares in brokerage accounts under his control in the names of those nominees, and then sold the 200,000
shares in large block trades effectively back to himself. The purchasers of the blocks were two other accounts controlled by Hayden at Research Capital. Hayden immediately began reselling SeaLife stock through the Canadian accounts, and continued selling over the next two months in small transactions. While Hayden was selling, Glaser, Griffin, Thomas, Wilbur, and
sometimes Hayden himself purchased the SeaLife stock being sold by Hayden. 40. In January 2003, Thomas received 500,000 shares of SeaLife stock, reissued it in
the name of ERT, and began distributing it through Wilbur. Thomas told Wilbur about SeaLife in early January 2003, and Wilbur's first activity was the purchase of 7,800 shares in nine market transactions at three different broker-dealers. Then, on January 21, 2003, Thomas transferred 50,000 shares of SeaLife stock to Wilbur, which Wilbur deposited into one of his accounts. After receiving the 50,000 shares, Wilbur continued to purchase SeaLife stock in small market transactions through his three accounts to support the price of SeaLife stock. 41. In February 2003, Wilbur sold the 50,000 shares he had received from Thomas
to the broker-dealer who held one of his accounts, along with 10,000 additional shares that he had purchased in the market, at a discount to the prevailing market price. The broker-dealer irnrnediately began selling the stock and sold all 60,000 shares in 17 small trades to market makers between February 4 and February 24,2003. Wilbur continued buying the stock in small transactions in his other two accounts while the broker-dealer was selling. Glaser, Hayden, and Griffin also purchased SeaLife stock at the same time that Wilbur's broker-dealer was selling. 42. Glaser transferred 50,000 shares of his SeaLife stock to Griffin. Griffin had the
stock divided into two certificates, opened a brokerage account, and deposited the stock in the account. Griffin sold 17,500 shares in market transactions between January 22 and February 4, 2003. Griffin then began buying SeaLife stock, and bought and sold the stock extensively
during February and March. By July 2003, Griffin had sold 36,800 of the 50,000 shares that he received from Glaser. 43.
Glaser distributed another 100,000 of his SeaLife shares through another client of
a broker-dealer where he opened an account in January 2003, and helped the distribution with his own purchases, financed in part with cash from Griffin. Glaser, Griffin, Hayden, and Wilbur all made purchases of SeaLife stock during that time which facilitated the distribution. 44.
p.m., Hayden sold 3,000 shares from his Sandwood account to Glaser for $.'I5 per share. e) On February 12, 2003, at 10:02 a.m., Hayden sold 2,500 sllares from his Ladan Reserve account to Thomas through ERT for $.70 per share. Then at 2:02 p.m., Thomas, through ERT, bought another 1,700 shares from Hayden for $.70 per share. 48. On other occasions, Thomas, Glaser, Griffin, Hayden, and Wilbur participated
in fraudulent stock trades in the public markets where SeaLife stock was effectively sold from one Defendant to another tlvough intermediate market makers. For example: a) On January 16, 2003, at 12:12 p.m., Wilbur bought 1,000 shares for $2.30 per share. Wilbur's stockbroker obtained the stock from a wholesale market maker who simultaneously obtained 1,000 shares for $2.15 per share from Hayden, tlvough Hayden's stockbroker. b) On January 23, 2003, at 12:38 p.m., Hayden bought 1,000 shares for $1.30 per share though his Ladan Reserve account. Hayden's stockbroker obtained the stock from a market maker, who, two minutes later, obtained 1,000 shares for $1.25 per share from Griffin's stockbroker, who was selling for Griffin. for c) February 4, 2003, at 3:22 p.m., Wilbur bought 1,000 sl~ares $.90 per share. Wilbur's stockbroker obtained the stock from a market maker. Within seconds, the niarket maker obtained the stock from another market maker, who obtained it for $ per share from a stockbroker selling 1,000 shares on behalf of Thomas, through ERT.
d) On March 4, 2003, at 2:51 p.m., Hayden sold 2,500 shares from his Sandwood account for $.70 per share to a market maker. One minute later, the market maker sold 2,500 shares for $.70 per share to Griffin's stockbrolcer, who was buying for
49. During the period of manipulative trading, Defendants' trading on numerous days
accounted the majority of trading volume in SeaLife stock in the public markets. For example: a) On January 17, 2003, Defendants' trading accounted for 86% of the total trading volume. b) On Febriary 7, 2003, Defendants' trading accounted for 90% of the total trading volume. c) On February 11, 2003, Defendants' trading accounted for 100% of the total trading volume. d) On February 12,2003, Defendants' trading accounted for 98% of the total trading volume. e) On March 7, 2003, Defendants' trading accounted for 76% of the total trading volurne
THE DEFENDANTS' STOCK MANIPIJLATION UNRAVELED
50. After it began trading in early 2003, the price of SeaLife stock reached as high as
$5 per share and fluctuated between $.60 and $2 per share during most of the period that the
Defendants engaged in the scheme. The Defendants' stock manipulation unraveled during March 2003, when they stopped working together to manipulate the stock price and no capital was provided to SeaLife. As the stock manipulation unraveled and the Defendants no longer artificially supported the price of SeaLife stock, the stock price declined below $.40 per share
where it traded most of the remainder of 2003. However, even after the manipulation unraveled, Defendants continued to distribute unregistered SeaLife stock to the public throughout 2003. E. DEFENDANTS DISTRIBUTED SEALJFE STOCK WITHOUT IWGISTRATION O R VALiID EXEMPTION UNDER THE FEDERAL SECURITIES LAWS 51. During the sche~ne,Defendants SeaLife, McCaslin, ERT, Thomas, Glaser,
Griffin, Hayden, and Wilbur caused SeaLife stock to be sold in transactions without registration or valid exemption under the federal securities laws. Registration on Forrn S-8 was improper because the Defendants sold SeaLife stock in a distribution to raise capital for the company and to promote and maintain the market for SeaLife stock. Defendants distributed nearly 1 million shares of SeaLife stock into the public markets, more than three and a half times the public float of the stock prior to the distribution. 52. As a result of the scheme, the Defendants received SeaLife stock proceeds in
brokerage accounts under their control as follows: Hayden received approximately $633,301 in proceeds; Glaser received approximately $16 l,in proceeds; Thomas and ERT received approximately $158,778 in proceeds; Wilbur received approximately $62,928 in proceeds; and Griffin received approximately $5 1,545 in proceeds. FIRST CLAIM FOR RELIEF FRAUD AND MARKET MANIPULATION Violations of Section 10(b) of the Exchange Act and Rule lob-5 [15 U.S.C. 5 78j(b) and 17 C.F.R. 5 240.10b-51 53. 54. The SEC realleges paragraphs 1 through 52 above. Defendants SeaL,ife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and
Wilbur, directly and indirectly, with scienter, in connection with the purchase and sale of securities, by use of the means or instrumentalities of interstate commerce, or of the mails, have employed devices, schemes or artifices to defraud; have made untrue statements of material fact
or omitted to state material facts necessary in order to make the statements made, in light of the circumstances under which they were made, not misleading; or have engaged in acts, practices or courses of business which have been and are operating as a fraud or deceit upon the purchasers or sellers of such securities. 55. Defendants SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and
Wilbur have violated and, unless restrained and enjoined, will continue to violate Section 1O(b) of the Exchange Act and Rule 1Ob-5. SECOND CLAIM FOR RELIEF FRAUD ANT) MARK_ET MANIPULATION Violations of Section 17(a)(l) of the Securities Act [15 U.S.C. 77q(a)(l)] 56. 57. The SEC realleges paragraphs 1 through 52 above. Defendants SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and
Wilbur, directly and indirectly, with scienter, in the offer and sale of SeaLife securities, by use of the means or instruments of transportation or communication in interstate commerce or by use of the mails, have employed a device, scheme, or artifice to defraud. 58. Defendants SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and
Wilbur have violated and, unless restrained and enjoined, will continue to violate Section 17(a)(l) of the Securities Act. THIRD CLAIM FOR RELIEF FRAUD AND MARKET MANIPULATION Violations of Sections 17(a)(2) and (3) of the Securities Act [15 U.S.C. $5 77q(a)(2) and (3)] 59. 60. The SEC realleges paragraphs 1 through 52 above. Defendants SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and
Wilbur, directly and indirectly, in the offer and sale of SeaLife securities, by use of the means or
instruments of transportation or communication in interstate commerce or by use of the mails, have obtained money or property by means of untrue statements of material fact or omissions to state material facts necessary in order to make statements made, in light of the circumstances under which they were made, not misleading; or have engaged in transactions, practices, or courses of business which have been, and are operating as a fraud or deceit upon the purchasers of SeaLife securities. 61. Defendants SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and
Wilbur have violated and, unless restrained and enjoined, will continue to violate Sections 17(a)(2) and (3) of the Securities Act. FOURTH CLAIM FOR RlELIEF PURCHASING DURING A DISTRIBUTION Violations of Rule 101 of Regulation M under the Exchange Act [17 C.F.R. 242.1011 62. 63. The SEC realleges paragraphs 1 through 52 above. Defendants Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur, directly and
indirectly, by use of the means or instrumentalities of interstate commerce, or of the mails, in connection with the distribution of securities of SeaLife, for which they were distribution participants; bid for, purchased, or attempted to induce another person to bid for or p~:~rchase, such securities during the restricted periods before they had completed their distribution. 64. Defendants Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur have violated
and, unless restrained and enjoined, will continue to violate Rule 101 of Regulation M under the Exchange Act [17 C.F.R.
5 242.1 011.
FIFTH CLAIM FOR RELIEF FAILURE T O FILE OWNERSHIP REPORTS Violations of Section 13(d)(l) of the Exchange Act and Rule 13d-1 thereunder [15 U.S.C. 5 78m(d)(l) and 17 C.F.R. S240.13d-11 Violations of Section 13(d)(2) of the Exchange Act and Rule 13d-2 thereunder [I5 U.S.C. 5 78m(d)(2) and 17 C.F.R. 5 240.13d-21
The SEC realleges paragraphs 1 through 52 above. Defendants McCaslin, Thomas, ERT, and Glaser acquired or otherwise became,
directly or indirectly, beneficial owners of more than 5 percent of the outstanding common stock of SeaLife, a security registered with the SEC pursuant to Section 12 of the Exchange Act, and each of them failed to timely send to the issuer of the security and to file with the SEC a statement containing the information required by Schedules 13D or 13G concerning their ownership of SeaLife common stock, and Defendants Thomas, ERT, and Glaser failed to make amendments to those schedules when material changes occurred in the facts that required the initial filings.
Defendants McCaslin, Thomas, ERT, and Glaser have violated and, unless
restrained and enjoined, will continue to violate Section 13(d)(l) of the Exchange Act and Rule 13d-1 thereunder; and Defendants Thomas, ERT, and Glaser also have violated and, unless restrained and enjoined, will continue to violate Section 13(d)(2) and Rule 13d-2 thereunder. SIXTH CLAIM FOR RELIEF FAILURE T O FILE OWNERSHIP =PORTS Violations of Section 16(a) of the Exchange Act and Rule 16a-3 thereunder [15 U.S.C. 78p(a) and 17 C.F.R. 240.16a-31
directly or indirectly, beneficial owners of more than 10 percent of the outstanding common stock of SeaLife, a security registered with the SEC pursuant to Section 12 of the Exchange Act,
and each of then? failed to timely file with the SEC a statement of the amount of all equity securities of SeaLife of which they were the beneficial owner, and Thomas, ERT, and Glaser failed to timely file statements indicating changes in such beneficial ownership of SeaLife cornrnon stock. 70. Defendants McCaslin, Thomas, ERT, and Glaser have violated and, unless
restrained and enjoined, will continue to violate Section 16(a) of the Exchange Act and Rule 16a-
SEVENTH CLAIM FOR RELIEF SALE O F UNREGISTERED SECURITIES Violations of Sections 5(a) and 5(c) of the Securities Act [15 U.S.C. 55 77e(a) and 77e(c)]
The SEC realleges paragraphs 1 tlvough 52 above. Defendants SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and
Wilbur, directly or indirectly, made use of the means or instruments of transportation or co~mnunicationin interstate commerce or of the mails to sell securities of SeaLife through the use or medium of a prospectus or otherwise, when no registration statement was in effect as to such securities; or to offer to sell securities of SeaLife through the use or medium of a prospectus or otherwise, when no registration statement was filed as to such securities.
Defendants SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and
Wilbur have violated and, unless restrained and enjoined, will continue to violate Sections 5(a) and 5(c) of the Securities Act.
EIGHTH CLAIM FOR RELIEF FALSE SEC FILINGS Violations of Section 13(a) of the Exchange Act and Rules 13a-ll,13a-13, and 12b-20 [15 U.S.C. fj 78m(a) and 17 C.F.R. $5 240.13a-11, 13a-13, and 12b-201
The SEC realleges paragraphs 1 through 52 above. Defendant SeaLife, directly or indirectly; and aided and abetted with scienter by
defendant McCaslin, in that he provided knowing substantial assistance to SeaLife; made material false and misleading statements in current reports on Form 8-K and quarterly reports on Form 10-Q filed with the SEC, and failed to include in such reports material information necessary to make the statements, in the light of the circumstances under which they were made, not misleading.
Defendant SeaLife has violated and, unless restrained and enjoined, will continue
to violate, and Defendant McCaslin has aided and abetted, and unless restrained and enjoined will continue to aid and abet violations of, Section 13(a) of the Exchange Act and Rules 13a-11, 13a-13, and 12b-20.
PRAYER FOR RELIEF
WHEREFORE, the Commission respectfully requests that the Court:
Find that Defendants SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur committed the violations alleged.
Enter an Injunction as to each defendant, in a form consistent with Rule 65(d) of the Federal Rules of Civil Procedure, permanently restraining and enjoining Defendants SeaLife,
McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur from further violations of the provisions of law and rules alleged in this Complaint.
Order Defendants Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur to provide an accounting for, and to disgorge, all ill-gotten gains in the form of any benefits of any kind derived from the illegal conduct alleged in this Complaint, plus prejudgment interest.
Order Defendants SeaLife, McCaslin, Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur to pay civil penalties, including post-judgment interest, pursuant to Section 20(d) of the Securities Act and Section 21(d)(3) of the Exchange Act, in amounts to be determined by the Court.
Order that Defendant McCaslin be permanently barred from acting as an officer or director of any public company pursuant to Section 20(e) of the Securities Act and Section 2 1(d)(2) of the Exchange Act.
Order that Defendants Thomas, ERT, Glaser, Griffin, Hayden, and Wilbur be pernlanently barred from participating in a penny stock offering pursuant to Section 20(g) of the Securities Act and Section 2 1(d)(6) of the Excllange Act.
Order such other relief as is necessary and appropriate. DATED: April 5,2005 Respectfully submitted,
Thomas J. fkysa, Esq. (303) 844-
Jolm B. Smith, Esq. (303) 844- 1025
Attorneys for plaintiff Securities and Exchange Co~nmission 1801 California Street, Suite 1500
Denver, CO 80202
Switchboard (303) 844-1000 Fax (303) 844- 1068
Kontopantelis et al. BMC Family Practice 2010, 11:61 http://www.biomedcentral.com/1471-2296/11/61
Patient experience of access to primary care: identification of predictors in a national patient survey
Evangelos Kontopantelis1*, Martin Roland2, David Reeves1
Background: The 2007/8 GP Access Survey in England measured experience with five dimensions of access: getting through on the phone to a practice, getting an early appointment, getting an advance appointment, making an appointment with a particular doctor, and surgery opening hours. Our aim was to identify predictors of patient satisfaction and experience with access to English primary care. Methods: 8,307 English general practices were included in the survey (of 8,403 identified). 4,922,080 patients were randomly selected and contacted by post and 1,999,523 usable questionnaires were returned, a response rate of 40.6%. We used multi-level logistic regressions to identify patient, practice and regional predictors of patient satisfaction and experience. Results: After controlling for all other factors, younger people, and people of Asian ethnicity, working full time, or with long commuting times to work, reported the lowest levels of satisfaction and experience of access. For people in work, the ability to take time off work to visit the GP effectively eliminated the disadvantage in access. The ethnic mix of the local area had an impact on a patients reported satisfaction and experience over and above the patients own ethnic identity. However, area deprivation had only low associations with patient ratings. Responses from patients in small practices were more positive for all aspects of access with the exception of satisfaction with practice opening hours. Positive reports of access to care were associated with higher scores on the Quality and Outcomes Framework and with slightly lower rates of emergency admission. Respondents in London were the least satisfied and had the worst experiences on almost all dimensions of access. Conclusions: This study identifies a number of patient groups with lower satisfaction, and poorer experience, of gaining access to primary care. The finding that access is better in small practices is important given the increasing tendency for small practices to combine into larger units. Consideration needs to be given to ways of retaining these and other benefits of small practice size when primary care services are reconfigured. Differences between population groups (e.g. younger people, ethnic minorities) may be due to differences in actual care received or different response tendencies of different groups. Further analysis is needed to determine whether case-mix adjustment is required when comparing practices serving different populations.
Background Access to health services is a prerequisite for any high quality health care system. Conceptually, access can be classified as a dimension of care on its own, separated from dimensions of quality [1,2] though it has more often been seen as one of the essential elements of
* Correspondence: email@example.com 1 National Primary Care Research and Development Centre, University of Manchester, Manchester, M13 9PL, UK Full list of author information is available at the end of the article
quality [3,4]. For the National Health Service (NHS), access is a high policy priority. The NHS Plan  in 2002 stated that patients should be able to see a health professional within 24 hours and a general practitioner within 48 hours, and in 2004, GPs were given a financial incentive to achieve this target Many GPs responded to the incentive by using a model of Advanced Access which attempts to match demand and capacity on a day-to-day basis . In the US, this model has been successful in both accelerating entry into the system and
2010 Kontopantelis et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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reducing the strain on clinical resources . However, many UK practices also substantially reduced the number of appointments that could be booked in advance in an attempt to meet the 24/48-hour target. This reduced patients ability to book ahead, and may have been one factor associated with a reduction in continuity of care , since patients found it harder to be seen by their preferred doctor on the day of their choice . The possible deterioration in patient access to primary care led the Department of Health to create the Improved Access Scheme, in an effort to evaluate and further improve access by incentivising the ability to book ahead as well as the ability to get appointments rapidly . The scheme used a patient survey to evaluate access, and since 2006, an annual survey has been used to measure a range of dimensions of access to GP surgeries, and to reward practices for their performance. The reports for the first two years of the survey indicated that positive experience and satisfaction was high in all five dimensions of access. However, the reports were limited to a descriptive exploration of the outcomes. In this paper, using data from the 2007/08 wave of the survey, we explore the factors associated with patient satisfaction and experience at the level of: (1) the patients; (2) the practices; and (3) the geographical region.
Page 3 of 15
list size, full time equivalent GPs, ratio of full time equivalent GPs per 10,000 patients, overall reported achievement on 48 stable QOF indicators (i.e. introduced in 2004/05 and with minor or no changes in the first 5 years of the scheme), distance to nearest practice, emergency admissions per 1000 patients, standardised mortality ratios of people under 65, number of new registrations, total opening hours and extended opening hours. Measures of global practice population deprivation and rurality were created by aggregating scores across the patients in each practice sample. We constructed practice population measures of ethnic mix, percentage of people in full-time employment and age profile, using both the practice samples and the 2001 census. Both estimates are prone to error (those from the sample due to self-selection bias; those from the Census due to changes since 2001), however, the two measures correlated well for ethnic mix (White v nonWhite; r = 0.856) moderately well for age (mean age, r = 0.614), but less well for rates of full-time employment (r = 0.537). In the analysis we used to estimates from the Census. Regional information was limited to three variables: Strategic Health Authority, number of practice staff in the PCT per 100,000 population, and walk-in centre attendance in the PCT per 100,000 population (walk in centres existed in 49 of the 152 PCTs) and had been established specifically to improve access to primary care.
We used multilevel multivariate regression to investigate relationships between each dimension of satisfaction/ experience and patient, practice and regional characteristics. The outcome variables were all binary (e.g. able/ unable to get an urgent appointment), therefore we utilised logistic regression. We began with univariate analyses, examining each predictor separately, and followed these up with a multivariate analysis to control for relationships between predictors. We included the patient, practice and regional level predictor variables in the same multi-level analysis. The size of the dataset made it not feasible to model the full hierarchical nature of the data (respondents nested within practices nested within regions), therefore we adopted a two-level model that took account of the nesting of respondents within practices, and assigned the regional variables to the individual practices. Although this may have introduced some small error into the p-values for some predictors, p-values have not been used to gauge the importance of each predictor. The size of the sample was such that very small differences in scores were statistically significant, making significance alone a poor guide to the effect of each predictor. Therefore to assess strength of effect we used
Table 2 Raw scores of satisfaction and positive experience on the five access domains
Access domains Q2 Q4 Q6 Q8 Able to get appointment with particular GP % 86.8 86.7 79.7 83.8 89.5 91.5 85.0 87.9 88.0 87.9 82.3 83.0 86.1 78.7 81.0 87.0 91.4 87.3 85.8 85.9 84.4 Q9 Satisfied with hours GP surgery open % 82.3 82.4 75.4 78.2 86.0 90.6 82.1 81.9 84.0 83.3 78.4 74.1 82.8 76.4 86.7 87.4 90.3 86.0 82.5 82.1 78.7 Satisfied with Able to get Able to get getting through appointment same appointment >2 on the phone day or next 2 days days in advance Patient level predictors Gender Age group Male Female 18 - - - 74 75+ Number of appointments (in last 12 months) 0-3 4-6 7+ Parent/legal guardian of any children under 16 in household Employment status No Yes Full-time paid work Part-time paid work Full-time education Unemployed Perm sick/ disabled Fully retired work Looking after home Something else Travel time to work Less than 10 min 10-30 minutes % 87.8 87.1 83.0 85.7 89.2 91.7 87.8 86.9 86.7 88.1 84.5 85.1 86.9 82.4 85.7 87.2 90.9 87.7 86.3 87.3 86.0 % 86.0 86.3 81.5 83.8 88.4 92.2 84.6 86.9 88.6 86.5 85.0 81.7 86.7 80.1 85.0 87.0 91.1 88.6 85.0 86.2 83.7 % 77.9 74.8 69.7 72.0 78.9 85.1 73.2 77.3 78.9 77.1 71.6 71.0 73.9 68.2 74.6 77.4 82.8 77.2 75.0 74.3 72.1
Page 5 of 15
Table 2 Raw scores of satisfaction and positive experience on the five access domains (Continued)
31 minutes 1 hour More than 1 hour Live on site Typical working hours Weekday office hrs Weekday mornings Weekday evenings or afternoons Overnights Weekends Other work pattern Working hours vary Can take time away from work to visit GP No Yes Substantial difficulties in day-to-day No activities because of long-standing hlth problem/disability Yes Carer responsibilities for anyone in household with long-standing health problem or disability Ethnicity No 84.1 82.1 89.2 85.5 87.2 85.4 80.3 77.9 86.6 82.2 87.2 85.6 70.0 67.7 76.6 71.7 74.7 72.2 82.1 79.0 87.8 84.0 85.9 83.1 70.0 63.4 83.1 73.0 85.8 83.7
85.1 84.0 85.5 85.7 77.4 88.6 87.6
84.3 82.4 83.3 83.3 73.7 86.5 86.1
72.8 68.3 71.4 71.6 60.6 76.6 75.7
83.1 81.4 83.7 83.9 75.7 87.2 86.9
81.6 78.9 78.8 78.5 57.6 82.7 81.8
Yes White British Other white Black Asian Other Deprivation c(33) = 12.2 and c(66) = 24.9 Low Medium High Rurality Practice level predictors Contract type Practice list size PMS* GMS** < 2,000 2,000 & <6,000 6,000 & <10,000 10,000 Full Time Equivalent (FTE) GPs 1 > 1 to 5 5+ Urban Rural
85.9 88.6 85.8 83.3 77.3 84.3 89.2 87.8 85.2 86.4 91.6 % 87.5 87.1 94.0 89.6 85.7 83.0 90.2 87.9 85.1
86.4 87.1 83.5 83.6 79.8 84.9 88.0 86.5 84.1 85.3 89.9 % 86.3 86.0 91.5 86.8 85.2 84.9 87.1 86.2 85.6
75.2 77.0 74.6 72.4 67.5 73.9 78.4 76.3 73.1 74.8 80.9 % 76.0 75.9 87.2 78.9 73.5 71.1 80.5 76.6 73.0
85.9 88.3 84.6 78.5 76.5 82.1 89.2 87.3 83.5 85.7 90.7 % 87.2 86.0 89.2 88.1 86.1 84.8 86.8 87.6 85.4
81.8 83.4 79.0 81.1 73.4 80.9 81.7 82.2 83.2 82.2 83.1 % 82.2 82.5 84.8 82.7 81.8 81.6 82.7 82.4 82.1
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Full Time Equivalence ratio per 10,000 patients c(33) = 5.1 and c(66) = 6.6 Low 86.0 84.4 74.8 85.6 81.6
Medium High Overall reported achievement (comparable indicators only) c(33) = 89.4 & c(66) = 91.9 Low
87.0 89.0 85.2
86.1 87.8 84.1
75.5 77.4 73.2
87.2 87.2 85.0
82.4 83.1 81.5
Medium High Distance to nearest practice c(33) =.223 & c(66) =.728 Low Medium High Emergency admissions for patients on list per 1000 patients c(33) = 69.1 & c(66) = 87.8 Low
87.1 89.7 86.8 86.4 88.9 89.8
86.2 88.2 85.4 85.3 87.8 87.7
76.1 78.6 75.3 75.1 77.5 79.9
86.8 88.4 86.2 85.6 88.3 88.9
82.4 83.1 82.6 81.9 82.6 81.3
Medium High GP referrals for patients on list per 1000 patients c(33) = 714 & c(66) = 850 Low
87.2 85.2 89.5
86.3 84.7 87.9
75.5 72.4 78.9
86.6 84.5 88.6
82.1 83.6 82.2
Medium High Standardised Mortality Ratio, people under 65 c(33) = 88.3 & c(66) = 113.9 Low
87.3 85.4 89.9
86.3 84.5 88.7
75.9 73.1 79.5
86.7 84.8 89.3
82.4 82.4 81.6
Medium High Number of new registrations c(33) = 343 & c(66) = 643 Low Medium High Total hours a practice is open a week c(33) = 30 & c(66) = 45 Below average Average Above average Extended opening hours Practice Index of Multiple Deprivation score (aggregated from patient sample) c(33) = 15.6 & c(66) = 26.7 No Yes Low
87.0 85.4 91.0 87.0 84.2 86.8
86.1 84.0 88.5 85.9 84.3 85.9
75.3 72.9 81.1 75.4 72.3 76.1
86.9 83.7 89.2 86.8 84.7 86.2
82.3 83.1 84.1 82.0 81.0 80.6
86.2 87.8 87.0 87.6 89.9
85.4 86.5 85.9 86.4 88.7
74.5 76.3 75.9 76.0 79.4
85.9 87.1 86.5 86.9 89.4
81.1 83.2 81.7 82.7 82.0
Medium High Practice rurality (% of sample patients living in a rural setting) c(33) = 0.4% & c(66) = 7.7% Low
87.1 85.2 84.6
86.2 83.8 82.9
75.4 72.9 73.8
86.9 83.6 83.7
82.3 82.8 80.2
Medium High Region predictors (practice-level)
87.2 90.2 %
86.6 89.0 %
75.2 78.7 %
86.7 89.4 %
83.5 83.3 %
Page 7 of 15
Practice staff per 100,000 population c(33) = 43.0 & c(66) = 73.5 Low 88.3 87.6 76.1 87.7 83.1
Medium High Walk in centre available in PCT Strategic Health Authority No Yes North East North West Yorkshire/ Humber East Midlands West Midlands East Of England London South East Coast South Central South West
87.7 86.1 87.7 86.7 89.6 87.7 87.2 86.6 86.9 87.4 84.2 88.0 89.7 90.9
86.9 84.2 86.7 85.1 87.2 86.1 86.3 87.3 86.4 87.1 81.7 88.6 87.5 89.2
76.5 75.3 76.2 75.4 78.3 74.4 76.0 73.3 76.3 75.7 74.6 75.3 79.2 79.9
87.1 85.4 87.1 85.9 87.7 86.7 86.9 86.2 86.3 87.3 83.1 87.9 88.9 89.9
83.1 80.9 82.5 82.1 86.3 84.7 84.3 82.9 82.9 81.9 77.5 80.6 81.8 84.4
* Personal Medical Services contract: an alternative contract offered by local authorities. ** General Medical Services contract: the standard contract under which practices are rewarded (65% of English practices) Continuous variables have been categorised using 33rd and 66tth percentiles for the purpose of this table Q2: all predictors significant at the 99.9% level (p 0.001) except: Substantial difficulties in day-to-day activities because of long-standing health problem/ disability (p = 0.460), deprivation (p = 0.002), contract type (p = 0.093), total hours a practice is open a week (p = 0.776), extended opening hours (p = 0.092). Q4: all predictors significant at the 99.9% level (p 0.001) except: deprivation (p = 0.282), contract type (p = 0.037), total hours a practice is open a week (p = 0.938), extended opening hours (p = 0.877). Q6: all predictors significant at the 99.9% level (p 0.001) except: carer responsibilities for anyone in household with long-standing health problem or disability (p = 0.988), deprivation (p = 0.053), contract type (p = 0.526), total hours a practice is open a week (p = 0.023), extended opening hours (p = 0.093). Q8: all predictors significant at the 99.9% level (p 0.001) except: gender (p = 0.013), carer responsibilities for anyone in household with long-standing health problem or disability (p = 0.072), contract type (p = 0.526), total hours a practice is open a week (p = 0.011), extended opening hours (p = 0.744). Q9: all predictors significant at the 99.9% level (p 0.001) except: gender (p = 0.008), rurality (p = 0.132), contract type (p = 0.526), distance to nearest practice (p = 0.005), GP referrals for patients on list per 1000 patients (p = 0.027), extended opening hours (p = 0.855).
Table 3 Associations between predictors and measures of patient satisfaction and experience, multilevel regression on all respondents
Access domains Q2 Q4 Q6 Q8 Able to get appointment with particular GP 804,561 8,038 ***0.812 ***1.085 ***1.266 ***0.969 ***1.276 ***1.599 Q9 Satisfied with hours GP surgery open 1,611,139 8,038 ***0.892 ***1.133 ***1.289 Able to get Satisfied with Able to get getting through appointment same appointment >2 on the phone day or next 2 days days in advance Number of patients in regressions Number of practices in regressions Patient level predictors Gender Age group Male Female 18 - - - 74 ***0.908 ***1.167 ***1.315 1,612,203 8,038 981,587 8,038 ***0.969 ***1.094 ***1.337 733,390 8,038 Standardised Odds Ratios
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Table 3 Associations between predictors and measures of patient satisfaction and experience, multilevel regression on all respondents (Continued)
75+ Number of appointments (in last - 3 months) 4-6 7+ Employment status Full-time paid work Part-time paid work Full-time education Unemployed Perm sick/ disabled Fully retired work Looking after home Something else Substantial difficulties in day-to-day activities because of long-standing health problem/disability Ethnicity No ***1.677 ***0.910 ***0.910 ***1.198 ***1.068 ***1.453 ***1.588 ***1.580 ***1.405 ***1.168 ***1.781 ***1.157 ***1.350 ***1.370 ***1.097 ***1.506 ***1.753 ***1.909 ***1.653 ***1.221 ***1.744 ***1.179 ***1.333 ***1.175 0.963 ***1.360 ***1.535 ***1.610 ***1.435 ***1.223 ***1.795 ***1.271 ***1.391 ***1.245 **1.083 ***1.176 ***1.512 ***1.718 ***1.457 ***1.266 ***1.483 ***0.872 ***0.921 ***1.746 ***1.381 ***2.665 ***2.885 ***2.945 ***2.401 ***1.802 -
Yes White British Other white Black Asian Other Deprivation Practice level predictors Practice list size Full Time Equivalence ratio per 10,000 patients Overall reported achievement (comparable indicators only) Emergency admissions per 1000 patients Number of new registrations Practice Index of Multiple Deprivation score (aggregated from patient sample) Region predictors (practice-level) Strategic Health Authority North East North West Yorkshire/ Humber East Midlands West Midlands East Of England London
***0.781 ***0.848 ***0.908 ***0.701 ***0.799 0.989 ***0.319 ***1.268 ***1.202 ***0.718 ***1.237 **0.869
***0.778 ***0.884 ***1.158 ***0.835 ***0.953 0.999 ***0.616 ***1.217 ***1.212 ***0.883 1.003 ***0.862
***0.826 ***0.867 **0.947 ***0.720 ***0.860 0.994 ***0.407 ***1.134 ***1.129 ***0.701 ***1.144 **0.854
***0.813 ***0.801 ***0.709 ***0.645 ***0.703 ***0.910 ***0.556 0.999 ***1.120 ***0.748 *1.068 *0.926
***0.805 ***0.846 ***1.134 ***0.725 ***0.893 ***1.199 ***0.839 ***1.065 ***1.087 0.989 *1.036 ***0.929
Standardised Odds Ratios
Standardised Odds Ratios **0.830 ***0.689 ***0.567 ***0.600 ***0.572 ***0.434 1.000 0.942 0.972 0.897 0.892 ***0.625 ***0.789 ***0.774 ***0.550 ***0.700 ***0.594 ***0.588 *0.893 ***0.839 ***0.699 ***0.758 ***0.703 ***0.607 *0.925 ***0.907 ***0.854 ***0.807 ***0.796 ***0.604
Page 9 of 15
South East Coast South Central South West ***0.546 ***0.762 ***0.717 0.983 0.912 0.961 ***0.543 **0.766 ***0.696 ***0.719 **0.846 **0.865 ***0.698 ***0.808 ***0.881
* = p < 0.05; ** = p < 0.01; *** = p 0.001 Predictors excluded from the table had no notable (0.86<OR < 1.18) association with any access domain
Table 4 Associations between predictors and patient satisfaction and experience, multilevel regression on working respondents only
Access domains Q2 Satisfied with getting through on the phone Number of cases in regressions Number of practices in regressions Patient level predictors Gender Age group Male Female 18 - - - 74 75+ Number of appointments (in last 12 months) 0-3 4-6 7+ Parent or legal guardian of any No children under 16 currently living in household Yes Employment status Full-time paid work Part-time paid work Travel time to work Less than 10 min 10-30 minutes 31 minutes 1 hour More than 1 hour Live on site Typical working hours Weekday office hrs Weekday mornings ***0.951 ***1.114 ***1.169 ***1.508 ***0.914 ***0.921 757,687 8,038 Q4 Able to get appointment same day or next 2 days 451,016 8,037 **1.032 ***1.044 ***1.184 *1.273 ***1.167 ***1.403 Q6 Able to get appointment >2 days in advance 337,432 8,038 Standardised Odds Ratios ***0.857 ***1.057 ***1.177 ***1.731 ***1.212 ***1.374 ***1.047 ***1.255 ***1.523 ***2.240 ***1.290 ***1.467 ***0.897 ***1.044 ***1.034 *1.188 ***0.871 ***0.960 Q8 Able to get appointment with particular GP 333,649 8,037 Q9 Satisfied with hours GP surgery open 757,067 8,038
Two categories of Typical working hours have been dropped because of multi-collinearity (Overnights, Weekends). Categories were small and the information they contained, regarding variation in satisfaction, was also present in other categories which were retained. * = p < 0.05; ** = p < 0.01; *** = p 0.001 Predictors excluded from the table had no notable (0.86<OR < 1.18) association with any access domain
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Table 5 Estimates of between-practice variance and percentage explained by patient- and practice-level predictor variables
All respondents Empty model Q2. Satisfied with getting through on the phone Q4. Able to get appointment same day or next 2 days Q6. Able to get appointment >2 days in advance Q8. Able to get appointment with particular GP Q9. Satisfied with hours GP surgery open
* Using empty model as reference
Working respondents only Empty model 1.24 (0.02) 0.84 (0.02) 1.34 (0.03) 0.64 (0.01) 0.20 (0.004) Full model 0.88 (0.02) 29.4% 0.67 (0.01) 19.9% 1.13 (0.02) 15.5% 0.48 (0.01) 25.0% 0.14 (0.004) 26.7%
Full model 0.94 (0.02) 29.3% 0.68 (0.01) 19.1% 1.08 (0.02) 17.6% 0.44 (0.01) 26.6% 0.15 (0.003) 23.9%
Between practice variance Practice variance explained* Between practice variance Practice variance explained Between practice variance Practice variance explained Between practice variance Practice variance explained Between practice variance Practice variance explained
1.32 (0.02) 0.85 (0.02) 1.31 (0.02) 0.60 (0.01) 0.20 (0.004) -
most instances lower amongst all non-white ethnic groups, most notably patients who described their ethnicity as Asian or mixed-Asian. The presence of longstanding health problems affecting daily activities was associated with reduced ratings in all domains. However, patients who were frequent attendees at their practice reported easier access to appointments. Patient gender only appeared to affect ability to book an appointment in advance. Practice size was a strong practice-level predictor, with larger practices receiving poorer ratings on all domains of satisfaction and experience. Figure 1 illustrates that in addition to having higher mean ratings, between-practice variability in access was also lower in smaller practices for most domains. For example, the standard deviations for satisfaction on getting through on the phone were: 23.8% for small (< 2,000 patients) and 37.6% for large practices (> 10,000 patients). Practices with a higher GP-to-patient ratio were reported as being better in terms of phone access and the availability of appointments within the next two days. Patients also found it more difficult to make appointments in practices serving more deprived populations. Two variables potentially measuring aspects of quality of care were also associated with scores on this questionnaire. Patient ratings were higher for practices with higher scores on the Quality and Outcomes Framework, and lower for those with higher rates of emergency admission. Relative to an 80% baseline, we estimate from the regression results that an increase in QOF reported achievement of 10 points was associated with an increase in satisfaction and experience rating of up to 3.4% (eg getting through on the phone: 3.2%, urgent appointment: 3.4%, advance appointment: 2.1%, appointment with a particular doctor: 2.0%). The only regional predictor of note was location, as defined by Strategic Health Authority. On most
those not. Inclusion of these interaction terms increased the between-practice variance in access ratings explained by the model by between one and two percent.
Discussion and Conclusions
Strengths and limitations
99% of practices in England were included in the survey resulting in a very large sample with almost two million respondents. The overall response rate to the survey was low (40.6%), and so results could have been affected by response bias. While previous research in patient satisfaction and experience with access suggests that non response is commoner among men,18 it is unlikely that any over-representation of females in the present case will have introduced bias since the effect of gender was estimated to be very small. It is also probable that nonrespondents tended to be younger (mean practice patient age in the sample was 53.8 and in the 2001 census it was 47.3). Since younger patients tend to be more negative in their responses, satisfaction and positive experience with access might have been overestimated.
Page 13 of 15
Table 6 Summary of patient- and practice-level interactions, from multilevel regressions on all respondents
Patient characteristic Not White White Under 45 yrs (18-44) 20% < 45 80% < yrs plus Not working Full-time 20% FT 80% FT Working full-time 20% FT 80% FT
Practice population1 Q2: Satisfied with getting through on the phone % Satisfied Effects2
20% White 72.7%3
80% White 87.4%
20% White 76.6%
80% White 89.4%
20% < 45
80% < 45
85.2% 89.1% 89.8% 92.6% 92.4% 88.2% 89.8% 84.5% Patient aged under 45: 0.912*** % Population aged <45: 1.072*** Interaction: 0.946*** Patient working FT: 0.831*** % Population working FT: 0.932*** Interaction: 1.003 ns
White patient: 1.076*** % Population White: 1.337*** Interaction: 0.955***
Q4: Able to get appointment same day % or next 2 days Satisfied Effects
85.0% 85.1% 89.5% 89.5% 90.9% 88.5% 85.2% 81.6% Patient aged under 45: 0.893*** % Population aged <45: 1.000 ns Interaction: 0.971*** Patient working FT: 0.772*** % Population working FT: 0.963** Interaction: 0.988 ns
White patient: 1.013** % Population White: 1.175** Interaction: 0.976***
Q6: Able to get appointment >2 days in advance
% Satisfied Effects
72.5% 76.5% 80.2% 83.4% 83.0% 79.8% 76.6% 72.6%
White patient: 1.056*** % Population White: 1.196*** Interaction: 0.946 ns
Patient aged under 45: 0.907*** % Population aged <45: 1.042 * Interaction: 0.995 ns
Patient working FT: 0.826*** % Population working FT: 0.969 ns Interaction: 1.001 ns
Q8: Able to get appointment with particular GP
82.9% 84.1% 90.0% 90.7% 90.5% 89.4% 85.3% 83.8%
White patient: 1.129*** % Population White: 1.153*** Interaction: 0.952**
Patient aged under 45: 0.841*** % Population aged <45: 1.016 ns Interaction: 1.011 ns
Patient working FT: 0.816*** % Population working FT: 0.984 ns Interaction: 0.971***
Q9: Satisfied with hours GP surgery open
75.2% 79.8% 83.5% 86.9% 88.0% 86.5% 75.9% 73.2% Patient aged under 45: 0.908*** % Population aged <45: 1.052*** Interaction: 0.904*** Patient working FT: 0.654*** % Population working FT: 0.981 ** Interaction: 0.992 ns
White patient: 1.043*** % Population White: 1.125*** Interaction: 0.989*
1 Population-level characteristics were used in continuous form in the regression analysis, but for descriptive purposes, results are presented for population percentages of 20% and 80% 2 Odd ratios from multi-level logistic regression on all respondents. 3 Estimated percentage from the regression model, controlling for all other factors in the model. * = p < 0.05; ** = p < 0.01; *** = p 0.001
However, a recent study of a later but similar questionnaire suggested that that response bias in practice estimates of access to care was small and not consistent in direction across individual questions in the survey . The representativeness of the total sample would also have been affected by the survey sampling design which, so as to obtain a minimum number of responses from all practices, relative to list size oversampled patients from smaller practices. Nonrepresentativeness may lead to bias in subgroup scores (Tables 1 and 2) as these are calculated without
weighting for sampling fractions and non-response, but is less of an issue for the estimation of the strength of relationships between variables, in this case the oddsratios from the multi-level logistic regressions. The analyses identify patient and practice characteristics that explain quite substantial percentages - up to 30% - of the variation in practice access ratings. Patient demographic factors with the greatest impact on satisfaction/experience, across all domains of access, were age (older people more satisfied), ethnicity (White British most satisfied, Asians least satisfied), and
Page 14 of 15
employment status (full-time employed least satisfied, retired people most satisfied). Amongst those in employment, we found that being not being able to take time off work to visit the GP was a key factor in determining responses across all domains. Other factors that freed up time, such as working part-time or having a short commute, were associated with more positive responses to the questionnaire. Despite substantial variation in reported practice opening hours, we found no notable relationship between total hours of availability and responses to any of the access questions - including satisfaction with opening hours themselves. This result held even among the working population. Practice size emerged from the analysis as the dominant practice-level factor influencing experience of access. Patients in small practices were generally reported easier access than patients in larger practices. Small practices were also less variable in terms of the access they provided. Satisfaction with telephone access was particularly increased in smaller practices. It may be that smaller practices can maintain a better ratio of telephone lines/administrative staff to volume of calls. This finding is consistent with previous studies, in which smaller practices were associated with high patient ratings of access and continuity of care [18-20]. Using the estimated coefficients from the full-sample regression analysis and a baseline level of 80%, the practice size effect on satisfaction and experience can be expressed in linear terms: a practice list size increase of 1,000 was associated with a reduction in experience and satisfaction of up to 2.4% (reductions relating to getting through on the phone: 2.4%, urgent appointment: 1.0%, advance appointment: 1.9%, and appointment with a particular doctor: 1.2%). As practices in the UK are tending to become larger, consideration needs to be given to how the potential benefits associated with small practice size can be retained. We found that patient ethnic identity affected reported satisfaction and experience on all domains of access. Many factors are known to influence the way in which different patient groups rate their care, including differences in health needs, expectations, and response tendencies, as well as experience per se [21-23]. Some research suggests that expectations are different in some ethnic minorities, even when experience is similar . However, we further found that the ethnic make-up of the area population had an impact on satisfaction/experience over and above a patients own ethnic identity. In particular, the larger the area non-white community, the more likely that both white and non-white patients were to give lower ratings on all domains of access after controlling for other patient and area characteristics. Comparing areas with small (20%) and large (80%) white populations, the area effect was consistently stronger than the association with
ethnicity of individual respondents. The area effect was also slightly greater amongst non-white patients. It is not obvious why there exists such a strong area effect, across both white and non-white patients, particularly once other factors such as area deprivation have been controlled for. It may be that individual expectations of care and rating tendencies are modified by the dominant views within the wider local community. These findings are broadly consistent with other literature on patient evaluations of their care. Studies in both the UK and in other countries have found that younger patients, patients from ethnic minority groups and patients living in socio-economically deprived localities tend to have less favourable evaluations of their care compared to older, white or affluent populations [24,25]. These differences could be due to differences in actual care received or to different response tendencies of individual population groups. If the differences are due to differences in care received, then the results can be used to identify areas where quality improvement should be focused. However, differences in response tendency of different population groups could be used as an argument for case-mix adjustment when comparing the results for practices serving different populations . Our finding of a strong area-ethnicity effect suggests that case-mix adjustment for ethnicity would need to consider area as well as patient characteristics in this respect, if it is to be at all accurate. Satisfaction and experience on some domains also appeared to be related to aspects of the quality of care provided by the practice - Quality and Outcomes Framework clinical indicator scores and rates of emergency admission. Previous research has not always found consistent relationships between access to primary care and rates of preventable hospital admission [27,28]. Our finding raises the possibility of a causal link between difficulty getting appointments and emergency admissions. This result merits further investigation, in particular whether availability of care in normal working hours influences demand for care out of hours, which is a time when many emergency admissions occur. Overall, the results of this study suggest a number of areas where responses to survey questions on access suggest areas for potential quality improvement.
Additional file 1: 2008 GP patient survey questionnaire.
24. Campbell JL, Ramsay J, Green J: Age, gender, socioeconomic, and ethnic differences in patients assessments of primary health care. Qual Health Care 2001, 10:90-95. 25. Elliott MN, Zaslavsky AM, Goldstein E, Lehrman W, Hambarsoomians K, Beckett MK, Giordano L: Effects of survey mode, patient mix, and nonresponse on CAHPS hospital survey scores. Health Serv Res 2009, 44:501-518. 26. OMalley AJ, Zaslavsky AM, Elliott MN, Zaborski L, Cleary PD: Case-mix adjustment of the CAHPS Hospital Survey. Health Serv Res 2005, 40:2162-2181. 27. Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, Billings J, Stewart A: Preventable hospitalizations and access to health care. JAMA 1995, 274:305-311. 28. Weinberger M, Oddone EZ, Henderson WG: Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. N Engl J Med 1996, 334:1441-1447. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2296/11/61/prepub
doi:10.1186/1471-2296-11-61 Cite this article as: Kontopantelis et al.: Patient experience of access to primary care: identification of predictors in a national patient survey. BMC Family Practice 2010 11:61.
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