interviews

Friends & family

The ‘friends and family test’ has proved a major success since its launch earlier this year in the NHS Midlands & East region, and will be rolled out nationally from next April. NHE spoke to Andrew MacPherson, director of customer service strategy and the Strategic Projects Team at the SHA cluster, who has been leading on the initiative both there and nationally.

How likely is it that you would recommend this service to friends and family?’ A simple question that can drive real service improvement and patient engagement.

Across the Midlands & East SHA cluster region, 31,472 patients answered the question in July, the latest month for which statistics are available – nearly 20% of acute inpatients, double the 10% rate that trusts are obliged to achieve under the CQUIN payment framework.

Andrew MacPherson heads the SHA cluster Strategic Projects Team that implemented the test.

He told NHE that the health service has “inevitably and quite appropriately” been focused on clinical outcomes, which has become deeply embedded in NHS culture.

But he added: “Of course that’s what we’re here to do, to achieve positive and effective outcomes. But the broader aspects of the patient experience haven’t been as prominent.

“We all know, with the climate of consumerism over the last few decades, increasingly patients feel like they are customers or should be perceived as customers and the broader experience, the overall impact of their episode of care and how it was for them, comes much more to the fore.

“If there’s a pecking order, then yes first and foremost may come clinical outcomes; but we do know people get better if they feel better and if they’re treated better, in terms of overall environment and all points of contact.

“What we’re going through in the NHS now is, arguably, the same sort of culture shift that retail and other service sectors in the world have gone through since probably the late 70s and early 80s – their understanding that every contact counts.

“It’s the entire pathway, from picking up your phone perhaps to your GP to seek an appointment through to your leaving the hospital car park if you’ve had some degree of treatment. That’s precisely the whole customer chain that web-based services and retailers on the high street have focused on. There are lots of high-profile brand names that have made successes out of that and successes of the methodology that sits behind it.

“We’re not trying to turn the NHS into a John Lewis as such; we’re just trying to ensure that culturally, as a system, the NHS recognises that the patient is a customer.”

Quantifying the patient experience

The test is not about catching hospitals out, MacPherson said – it should be about focusing on success, and making information available easily to patients so they can see how their provider is doing.

We asked how closely the data so far seemed to correlate with other clinical outcome statistics and health indictors.

He said: “We’ve got four to five months of data under our belt, though it is still quite early days if you allow for early distortions in a system still bedding down.

“Having said that, early indications are that it is providing a very valuable insight into what matters most to our patients/customers.

“I’m not going to name names at the moment but we’ve had examples of an acute that presents excellent clinical outcomes overall, but the perception in the friends and family test tended towards the negative.”

The trust in question looked into it, MacPherson said, and discovered that the factors dragging its scores down were things like noise at night, cleanliness, and poor lighting.

He said: “This illustrates my earlier remark, that the tendency is to focus (quite rightly) on clinical outcomes but sitting alongside that are all the nuances that anybody as a patient will understand do affect your overall satisfaction.

“You may have had your hip replaced, but if you’ve had three or four days of sleepless nights or appalling food, or you had to wait hours to be attended too, those are headline grabbers. We’re trying to formalise that.”

Asking the question

The SHA cluster is being “highly permissive” in how it lets trusts ask the question, MacPherson said.

As was discussed in the July/August edition of NHE, further expanded on by Patients Association chief executive Katherine Murphy on page 72 of this edition, some patients and their families choose to ‘keep quiet’ about concerns while they are in hospital, “in case something happens”. This is almost always a misplaced fear, of course, and frustrating for patient groups and hospitals themselves.

We asked whether such concerns were a factor in the friends and family question being made generally post-discharge.

MacPherson said: “We do recognise that if the sample or the question is asked within the care environment, it can be skewed, for all sorts of reasons. It may be some misplaced fear that people think it may affect the relationship between them and the clinician.”

He said the perception that complaining could lead to worse service is common to all sectors – retail, transportation, and so on.

He continued: “We do recommend or prefer that the question be responded to away from the point of care, if only to be able to reflect independently on the circumstances. It may not be always appropriate: the last thing we want to do is pester people for feedback when they’re probably quite keen to leave and get home.

“Having said that, some organisations are sampling within the clinical environment and sampling very effectively. There is a treatment centre in Nottingham that introduces the question at the very beginning of the process but says ‘we’d like you to answer this at some point, would you please consider completing it before you leave’.

“It’s about whatever suits the patient and what is the most effective way of getting that information back into that trust so they can understand it and act upon it.”

For all to see

The headline findings of the data – most notably an overall ‘score’ for each trust, obtained by subtracting the percentage of ‘detractors’ from the number of ‘promoters’ – is published online.

The latest data, covering July 2012, shows a massive range in trust scores, from 48 (Peterborough & Stamford) to 91 (Robert Jones & Agnes Hunt). The mean score across the region was 67.

We asked MacPherson how important this public release of the data is – or whether the main thing is hospital trusts acting on the data themselves to improve services.

He said: “For this dataset, this is the key to it – making it accessible and for everybody. It is a shared reference for both the patient and the clinical practitioner.

“If we are going to create a really customercentric NHS and provide a real ‘service with a capital S’, it will mean a convergence of culture change within the providers and culture change within our patients in terms of getting them to understand they really are consumers.

“Patients have a role to play in providing accurate, helpful and constructive information in real time to our clinical practitioners to make sure that, firstly, their experience is optimised and that they have the best quality outcome, and secondly that we’re smarter with the money.”

He said the “passion” shown by some NHS staff for their work was immense, but he added: “Publishing this data is a huge incentive: people are naturally competitive and interested in what their efforts are producing above and beyond, in this case, clinical outcomes.

“Everybody likes to be liked and encouraged, particularly in areas of the NHS where people work particularly hard in the clinical environment – this highlights how they’re doing.

“It’s early days but you’ve only got to look at the fact that all 46 trusts in the NHS Midlands and East are not only reporting but they are reporting weekly, which is a huge leap forward; they’ve almost doubled the minimum requirement.”

‘From ward to board’

But the data is not useful just at the trust and intra-trust level: it is broken down to ward level, although for now that data remains an ‘internal metric’, not public. MacPherson implied that could change, saying it is not publicly reported “yet”.

He said a range of secondary questions are coming in, such as ‘what is the main reason for the score you’ve given’, to see if the patient’s response had more to do with their care, or car parking, or staff attitudes, for example.

MacPherson said: “We want to make sure it is covering all aspects of the overall experience, which can colour people’s perceptions even if they’ve had the most outstanding clinical care.”

The overall trend so far has been gradual but upwards across the region: month-on-month since April, the overall number of ‘promoters’ has risen, while the number of ‘detractors’ has fallen.

National roll-out

MacPherson’s team has been working with the other SHA clusters and the DH on the national roll-out of the friends and family test. The DH confirmed in May that the test would go national, following a recommendation from the Nursing Quality Care Forum.

Prime Minister David Cameron said then: “In every hospital, patients are going to be able to answer a simple question: whether they’d want a friend or relative to be treated there in their hour of need. By making those answers public we’re going to give everyone a really clear idea of where to get the best care – and drive other hospitals to raise their game.”

The national backing was warmly welcomed by the Midlands and East SHA team who devised the test originally as the headline metric for its ‘Patient Revolution Ambition’.

MacPherson said the national version would be run in a similar way to the regional one: “There may be some nuances around the questions but the underlying question will be the same and certainly the objectives will remain the same: creating a catalyst for change and a truly customer-centric NHS.

“We’re not blind to improving what we’ve got [in the Midlands & East], we’d be very arrogant if we were, but we are committed to making sure we’ve got a minimum of 12 months data first because if we keep chopping and changing it will inevitably create distortions.

“This is all about celebrating success and what the NHS is good at.”

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