Patient satisfaction guaranteed: the future of payment by results?

Last week, health secretary Andy Burnham said payment by results “needs to do what it says on the tin”.

He promised to “progressively link a much bigger proportion of a trust’s income to quality and, importantly, levels of patient satisfaction”.

You do not have to have strictly comparable measures of performance between trusts; you just need to identify what you want from a particular trust

John Appleby

Staff satisfaction, too, should be more explicitly connected to quality, he said. When staff are not happy, it is often an “early warning sign” that quality of care is not up to scratch either. Staff satisfaction is to be measured “more systematically”, he said, and used as a “helpful barometer” of patient care.

The drive for quality at the heart of former health minister Lord Darzi’s next stage review is not new, but the commitments have been taken as a sign the health secretary is making an “extra push” to bring the vision into practice.

Welcoming Mr Burnham’s announcement, NHS North West chief executive Mike Farrar says there must be a “rounded definition of quality” that includes patient experience. Patient experience has now been added into the region’s Advancing Quality programme, which is frequently cited as being at the vanguard of the quality drive.

If clinical outcomes are improved but patient experience is not, “it won’t feel real to people when we say it’s a higher quality service”, says Mr Farrar. Moreover, “there’s good evidence that if patients feel they have been treated well [then] they feel more involved in their care and we get even better outcomes as a consequence”.

Neil Bacon, the founder of the ratings website iWantGreatCare, where patients post their reviews of NHS services, says the idea is “well overdue”.

“I think it’s going to really expose those that do not focus on the patient and have had it easy for too long,” he says.

Many people would not book holiday accommodation if it was not listed on the ratings site TripAdvisor, and “the same thing will happen to hospitals”, he predicts.

Introducing payment for patient experience is, however, not simple. The incentives need to be right and measurement must be meaningful.

NHS Confederation policy director Nigel Edwards says the principle that NHS organisations should measure things that are important to patients and staff is a good one, but care must be taken in how the feedback is captured and how much weight it is given.

There are risks, he says, in paying people for doing things “which they should be intrinsically motivated to do”. Part of the job of NHS chief executives is to bring inspiration and moral purpose to their organisations. Health professionals’ sense that “I’m doing this because it’s right, not because I get paid for it” must not be “crowded out”, he warns.

There must also be consideration of when in the treatment pathway patients are asked to rate their experience, and how many questions they are asked - five would be better than 40, for example, he says.

Large samples

Because patient satisfaction is generally quite high, trusts will need large samples to demonstrate statistically significant improvements. Similarly, if comparisons between areas are required, surveys need to be designed to ensure apparent differences reflect genuine variation in quality of services.

However, King’s Fund health policy chief economist John Appleby argues that patient experience does not have to be comparable.

Since the NHS “is almost a series of bilateral monopolies”, many primary care trusts cannot, in practice, take their business elsewhere if they are not happy with services, he says. But commissioners can put pressure on providers to do better, and one way to do that is by negotiating some of the price so that it depends on performance measures.

“You do not have to have strictly comparable measures of performance between trusts; you just need to identify what you want from a particular trust. An element could be to do with patient satisfaction, another element could be to do with staff satisfaction,” Professor Appleby says.

Picker Institute Europe head of policy and communications Don Redding says it is perfectly possible for commissioners and providers to use local measurement systems to set targets for improvement and monitor their achievement.

But he warns: “That’s open to quite a lot of risk of poor question design, bias in patients’ reports and inconsistent measurement. Also it’s very important that people collect demographic data because if you can’t adjust the data for age, ethnicity and gender you may be getting misleading reports.”

He would like more guidance for trusts.

“Now that the NHS is instituting much more widespread and frequent measurement of patient experience what we are finding is there’s an awful lot of confusion out there about what patient experience is about, what it’s for and where to start.”

Mr Redding is also wary of the health secretary’s apparent conflation of patient experience and patient satisfaction - he used both terms in his speech last week - and says it is important the difference is understood. Satisfaction measures are too general and too vulnerable to subjective factors to enable trusts to know what to improve.

“The emphasis on experience is about accurately measuring what’s going right and wrong and having a clear light on where you can take action to improve.”

Mr Redding hopes the emphasis Mr Burnham put on staff satisfaction will make the staff survey and the patient survey more comparable.

“We would like to see staff being asked to report on some of the same aspects of care that patients are asked to report on, to try to get staff to report on how patient centred the care is,” he says.

NHS director of workforce Clare Chapman says these kinds of changes to the staff survey are already being made. The survey has been reorganised around the four staff pledges made in the NHS constitution, she says, and as it becomes law there will be greater alignment in the service between the constitution’s staff pledges and patient pledges.

This is “really highlighting the fact that it’s empowered expert patients and empowered staff that can drive reform. We need both”, says Ms Chapman.

She says the redesigned staff survey will mean “every organisation can see how it’s doing and calibrate its achievements and improvement plans where it’s got gaps”.

She expects trusts to include staff satisfaction in their quality accounts.

The next step is to make the data available to patients in a way that enables them to ask “is this the sort of place I would want to be treated in?”.

Dynamic survey

The Department of Health has added a question to the staff survey on whether they would be happy with the standard of care at their organisation if a relative required treatment. The survey’s improvement board, which Ms Chapman chairs, is working on how to make it more “dynamic”.

“I want to keep it static enough that you can compare year on year but as you learn where the connections are between patient and staff satisfaction you would want to make sure that you keep the staff survey learning from that.”

NHS Employers director Sian Thomas says: “Most organisations have analysed their results by service and by business unit. What they have not done is be open to the public about that [service by service].”

She says improvements in quality come when teams “own” their performance data and share and compare it.

As staff satisfaction and patient experience are more explicitly linked to quality - and payment - many argue that now more experimentation is needed.

Mr Edwards says: “You can do national development but you can do experimentation too. It’s not an either/or.”

If payment by results is to do what it says on the tin, the results are what matters.