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Public engagement with service information is key test of choice

The net promoter score dominates the measurement of customer satisfaction. Indeed many HSJ readers will have contributed to the title’s annual NPS survey.

Respondents are asked if they would recommend a service or product to others. The number who say they would not is subtracted from those who would and an overall score is produced. Across the world millions of corporate reputations and careers hang on NPS results.

The score arrived in the NHS via NHS Midlands and East, the laboratory for many of the radical ideas now being spread across the service. It was disguised under the title of the “friends and family test”. Results are broken down by ward and specialty and performance will affect funding under the commissioning for quality and innovation scheme.

Prime minister David Cameron confirmed his interest in the idea last week in response to a recommendation by the government’s Nursing and Care Quality Forum. Soon it appears every NHS hospital will have its own patient NPS.

The implementation of the system in NHS Midlands and the East has not been uncontroversial. Some leaders in the region have found it distracting and time consuming for staff. They dislike the weight being given to it – when compared to other measures which they believe are more robust and useful.

But it seems unlikely the tide is going to turn. The NHS Commissioning Board has sent a clear message in appointing Dr Foster founder Tim Kelsey as its director for patients and information. Mr Kelsey is a fierce champion of using data to inform patient decisions with a track record of challenging accepted wisdom. He is likely to work hard at ensuring clinical commissioning groups embrace measures of “customer satisfaction”.

There will always be arguments as to the relative weight that should be given to measures that do not directly record clinical outcomes. But few would argue NHS patients would not be happier if more attention was paid to improving the experience of care.

Bupa claimed earlier this year that its customers reported lower satisfaction when treated in NHS private patient units compared with independent providers. Those who dismiss the issue as irrelevant need only read our cover feature and contemplate how much time and energy is consumed by managing problems created by car parking.

You do not have to be a conspiracy theorist to link the push to measure NHS “customer” satisfaction with the moves to accelerate choice for patients. Mental health and diagnostics are the latest frontiers to be explored The Department of Health is also accelerating efforts to establish a “level playing field” for all providers ahead of the new competition regime being established.

The goal is that, before the next election, the population will have become comfortable with and enthusiastic about the idea that services spending NHS funds must demonstrate to the public their ability to provide a good quality healthcare “experience”, an experience which includes both clinical and non-clinical factors. This, it is hoped, will encourage commissioners to offer their populations a range of providers that are able to prove their worth.

Patient preference is the lifeblood of the new system. If patients ignore or reject the information on services as irrelevant or unhelpful it will have little legitimacy. Most NHS leaders know conversations among patients and their relatives have a profound impact on a provider’s reputation. On that basis the friends and family test could prove the measure which engages the public’s attention in a way so many previous, more technical, methods of expressing service quality have failed to do.

Readers' comments (13)

  • There is a good reason why accross the world millions of corporate reputaions and careers hang on NPS results. It has been proven to work.
    The problem with the NHS is that it's been allowed to build itself around the staff. The NPS will force us to deliver what patients want which may not always be the same as what we think they need or what we want to give them, and if patients want what we percieve to be suboptimal solutions then that's democracy at work!

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  • Only problem is the tool was designed to measure customer loyalty. Tools only do the thing they were designed for ie how well your doing at making sure customers come back and don't flit off to your competitors.

    I've used NPS for loads of things and its useful for determining activities that build a positive reputation ... no offence, but to do well, we don't want our customers to come back!

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  • I hope this initiative will support a culture change. I agree that the NHS has been built around staff. This is not meant perjoratively as staff who work in the NHS are very committed and hard working. However the predominant ethos tends to be a tad paternalistic and/or patronising. I have the utmost respect for clincial skills & knowledge but my health is my health. More often than not, when I use any health services it seems that I become the property of the clinicians.

    I hope there will be some detailed consideration of what 'satisfaction' and a good experience is for patients not least because excellent 'customer care' could easily mask unacceptable clinical care. As well as knowing what standards of service to reasonably expect, I'd want to know what the likely outcomes of any intervention are likely to be so that I would be better informed to judge whether I'm satisfied with the service provided.

    A culture change for patients is also needed - to take more responsibility (when able to/with appropriate support if needed) but this can't happen until the required pivotal change in the NHS. I'd be interested to know if there are better outcomes for patients when we have more influence and control over the care we receive. And, if so, is this more pronounced in particular types of service? It strikes me that this collaborative-style approach may take a little longer in the short term but could reduce time (& hence costs) in the longer term because there is a greater chance of care meeting individual needs.

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  • Lets just take a slight reality check here. It's really, to my mind, pretty over-simplistic to say the NHS is built around the needs of the staff. If we start constantly from that point we're tilting at windmills.

    Our services are, however, often built around a series of more pragmatic and practical limitations and constraints. Availability of staff with the right clinical skills; the need for critical clinical mass; the value of Team working; the need for appropraite infrstructure to support care; the hard fact that this can't be available everywhere many patients might like it 24/7.

    You could equally argue some service industries are built around the needs of their staff because I can't pop in to my local bank or Kwikfit 24/7, 365 days a year.

    But that doesn't negate the pressing need for greater patient involvement in decision-making, whether in their own care or dveloping/assessing service generally. And we need to be better, franker and more transparent about those discussions. What doesn't help is starting those discussions from limited generalisations.

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  • Err, is it just me or is this question not already asked of most NHS services??

    Certainly, if I go to NHS Choices and look up any hospital, GP, dentist etc I'm asked to say if I would 'recommend' the place to a relative or friend. And I can see the aggregated recommendations of others.

    Also, the NHS staff survey asks the same question of NHS staff working in hospitals. This too is published on Choices.

    Now I can understand the PM re-heating this sort of thing in order to pocket a few more votes – and good luck to him, he’s a politician after all.

    But for the HSJ and a number of other NHS bigwigs to fall for it ….. well, it makes you wonder what the world is coming to.

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  • Let us imagine, for a moment, that you are blind. Or Deaf. Or hard of hearing. Or that English is not your first language. That you are a young child or an elderly person with dementia, or aphasia. You have a less-than-satisfactory experience in hospital.
    If, by some means, you manage to complete the Friends and Family test, and score 0 or 1, so what?

    Who will know why you gave a low score? Who will know what could be done to improve the experience?

    Now, let us imagine that you are an educated, articulate, middle aged woman. You have a bad experience in hospital. Not wanting to register a complaint, you have the opportunity to respond to the F&F question. You score 0.

    So what? Who will know what went wrong? Who will know what could be done to improve the experience?

    Let us imagine now that you were one of Harold Shipman's patients. You love your GP. You give him a score of 10.

    What then?

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  • Anon at 9.07pm asks what happens after consumers give an NHS organisation a low score.

    Well, in the real world, a company that gets rated poorly by a large number of its users tends to go out of business. That is unless its management takes it upon itself to find out why their business is being rated so badly and then reforms things.

    For patients though, its a win win. If a place is rated poorly, you can see that and go elsewhere.

    If management and regulators choose to ignor the ratings (as they did in the case of midstaffs) more fool them. The system is here for patients, not managers after all.

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  • I think Anon 9.07 makes an even more interesting point, which is how people score, based on their personal impressions. Not necessarily mortality statistics or revision numbers or MRSA rates. They may think an individual is good because they are kind/ helpful/ patient - but this tells us nothing about their practice or competence. To me this suggests that the scores should be used carefully and in a balanced way. And perhaps suggests a research project, looking at correlation between scores and other variables. Thank you Anon 9.07 for making me think!

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  • The value complaints and feedback from patients is motherhood and apple pie. The NHS should make it easy for patients to record their experience and they do not need to ape the private sector where much thought goes in manipulating customer perception and loading the presentation of statistics.

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  • Anon at 11.41, the research looking at correlations between patient rating of hospitals on NHS choices and actual measures of mortality, MRSA infection etc has already been done by Imperial college london. The correlation is v strong, suggesting that the crowd really is wise. So marked were the results that David Nicholson copied them to all NHS chief execs in his monthly newsletter. His point, i think, was to get NHS staff looking at (and acting on) the many hundreds of consumer ratings they already recieve rather than dreaming up excuses not to...

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  • Hello 11.21, this is 11.41 - is there any chance you could paste the link to that work please? Forgive my ignorance, I didn't know about this and it sounds very useful. Many thanks!

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  • The "friends and family question" has been asked in every national in-patient survey since they started back in 2002 with CHI. It's not new. It's been publicly available for every single hospital in England over the past decade:

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  • If I've been keeping up, this particular 'friends and family test' is an implementation of the Net Promoter Score commonly used in hotels and other service industries. I can see this could be of benefit - particularly since at least one company seems to have been redesigning this tool specifically for NHS patients.

    I do wonder, though, whether a preference for novelty is again leading decision-makers to ignore what already works.

    Although sadly I don't (yet) get paid for doing so, I'm a pretty regular promoter of - a website that allows patients to give a free-text description of their NHS care.

    Trusts which have signed up for PatientOpinon's full feature set will get this feedback routed to the appropriate service managers, who will be able to respond to the patient and outline any changes made as a result of their comments. The site also pulls in patient comments left on NHS Choices.

    In the last 18 months, 279 changes have been made as a result of patient feedback through PatientOpinion. The approach is demonstrably effective; if more trusts signed up and actively promoted services like this to patients, it might prove more effective in driving positive improvements than yet another headline figure.

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