Published: 06/10/2005 Volume 115 No. 5976 Page 28

Professor Ellie Scrivens is director of the Health Care Standards Unit at Keele University, which receives funding from the Department of Health. The views expressed here are those of the author and not necessarily those of the DoH.

Standards for Better Health emphasises the message that patient choice and improving the patient experience are central to improving the NHS. The standard C14 included in the patient focus domain requires that NHS organisations deal with complaints appropriately and act upon them. Poor handling of complaints not only generates high levels of dissatisfaction, but can rapidly generate a poor reputation for the whole organisation.

In 1990, Karl Albrecht and Ron Zemke published a book called Service America. They suggested that for every customer who has an unresolved complaint or problem, 26 other people will hear about it first, second or third hand.

Similarly, the New Zealand government website states that negative word of mouth is spread and believed at twice the rate of positive word of mouth. And in e-commerce, dissatisfied customers are almost four times more likely to discuss their e-experience in an online chat room than are satisfied customers.

The increase in public expectations of health services has led to a marked rise in complaints.

This trend started in 1999 and recent statistics suggest it is continuing. The complaints frequently relate to the way patients feel they have been treated and the attitude of staff towards them, according to the health service ombudsman's 2002 report. Onethird of complaints against doctors who are Medical Defence Union members are about attitude and communications problems.

There are two aspects to quality of service delivery - functional quality and technical quality. In healthcare, technical quality relates to clinical aspects of care, whereas functional quality relates to how patients feel they are treated. In the past the NHS has concentrated not on functional quality but on peripheral aspects of service - environment, catering etc.

Although important, these lead to a model of quality that revolves around what service deliverers think is important rather than what patients value. In most service encounters, consumers are coproducers in that they are part of the production process. Their views of quality are determined by their experience of interactions with staff.

Fish, a book by Stephen Lundin, is based on an analysis of the Seattle fish market, and in it he suggests some areas for managers to concentrate on:

Make their day: is it possible to make each contact enjoyably memorable? When NHS staff receive compliments for their work it is frequently when they have shown small kindnesses to patients.

Be there: the antidote to burnout is not necessarily rest, but wholeheartedness. It is the halfhearted things you do while juggling other things that wear you out.

Choose your attitude: if you find yourself with an attitude you do not want, you can choose another.

e. j. scrivens@keele. ac. uk