interviews

The Friends & Family Test: challenges and opportunities

Andrew MacPherson, managing director of The Strategic Projects Team, originally part of NHS Midlands & East and now hosted by the Greater East Midlands CSU, has had a major role in the development and then implementation of the Friends & Family Test. Ahead of the next stage of the roll-out, he spoke to NHE.

Q) How have you been involved in the FFT?

I cut my teeth in sectors having to ‘up their game’ in terms of their customer service as they faced economic challenge and increased consumer expectation. This scenario is not unlike the NHS, which I joined formally in 2009, to set up The Strategic Projects Team. In 2012, while pursuing a broader agenda for sustainable service excellence, I (along with co-creator Dr Stephen Dunn) designed, launched and delivered the NHS Friends and Family Test (FFT), initially in the Midlands and East region.

FFT was introduced nationally after prime minister David Cameron recognised its significance in 2012 and announced its roll-out across the NHS. We were then engaged by the Department of Health and latterly NHS England to manage the roll-out of FFT in A&E, acute inpatient and maternity services across the country and initiate the guidance for other pathways.

Q) How has the FFT been received?

It has not been without its challenges. It’s fantastic when the government of a country gets behind something like this, but inevitably it introduces a new dynamic to something we always saw as a ‘ground-up’ movement. The perception of FFT will inevitably continue to swing between that of a traditional ‘performance’ metric and our original intention: that of a culture change driver.

Q) And how do you feel FFT is making a real difference to patient care?

It’s certainly making a positive difference to patient care in terms of provider behaviours. Like any embryonic transition, those behaviours will vary and that more traditional interpretation of ‘yet another performance metric’ to pillory, can be quite counter to FFT’s positive change agenda.

FFT is about much more than just ‘the score’. The headline score generates an appetite for asking ‘why’ a patient gave their answer, creating a wealth of insight available from ‘ward to board’. The true success of FFT is that it has enabled providers to make changes to their services, and has directly improved patient experience through celebrating success and trapping shortcomings. It has the potential to deliver a true cultural change by putting the patient’s overall experience openly at the centre of care.

By progressively empowering every provider or commissioner employee to see the ‘near real time’ impact of their day-to-day contribution (or that of their organisation) to each patient’s overall care, it should represent a revolution in patient experience

Q) Are there any changes you would make to the FFT?

There are still, inevitably, gaps. FFT’s status as a ‘national statistic’ is impressive, but again the necessary rigid control is sometimes counter to the ‘near real time’ concept of shared data for all at any time. The latter is being achieved depending upon the sophistication of local platforms, and this is where real empowerment can lie.

In the Midlands and East 2012-13 roll-out, data was published in a much shorter window and was made available simultaneously to CEOs, clinicians, caterers – everyone involved in the patient journey.

I am sure that’s an aspiration for the national transparency and insight agenda, but the original FFT vision will not be complete until it happens.

Q) It sounds like there is a lot of scope for it to be rolled out further?

I have recently completed a series of FFT workshops with over 1,000 GPs and practice managers. It’s an environment of mixed response, although it’s no different to our experience when rolling out to acute care across the country. There are people seizing the opportunity, reeling from it, and rejecting the initiative.

The principles of FFT insight present a huge opportunity for all public services, if they remain true to the objective of customer/provider empowerment. That empowerment resonates with the ‘Collective Leadership’ research by, for example, the King’s Fund. What you are (potentially) seeing in the NHS is exactly the same change that retail, transport, utilities and some professional services went through in the 90s; becoming increasingly customer-centric; recognising the productivity opportunity through employee satisfaction and a shared ownership of business objectives.

Q) How do you think the FFT changes relationships between patients and clinicians?

There is a long way to go in communicating and marketing to the public their role in this change, let alone their understanding of FFT.

The system has also had trouble in articulating the underlying methodology. In early 2013, the change to a six point, rather than the more traditional Net Promoter System (NPS) 10+1 point scale, while a well-meaning attempt at simplification, was always a potential recipe for confusion, as the sector started to tinker with a globally established methodology.

We shouldn’t underestimate the ability of organisations to adapt, mature and reach new heights of service sophistication. Over-simplification won’t serve that potential in the longer term.

Q) What’s next for FFT?

On the whole FFT is certainly making an impact – we can see this with how it’s been gradually welcomed across secondary care and now primary care. We mustn’t lose sight of mental health and community services (the latter being one of the earliest ‘voluntary’ adopters to use it to enhance patient dialogue), plus, ideally, its application across all the pathways of public service.

Public engagement and the understanding of their role would be far greater if the question was experienced in all their interactions, not just healthcare.

I don’t mind which of the many possible indicators we use to calculate patient experience, as long as we use this information to create a culture that is focused on transparently listening to patients and responding to their feedback.

In my personal experience, however, the original NPS had significant impact and appeal for clinicians early on during the Midlands and East launch, because of its significant track record outside the healthcare sector.

Apart from the global adoption of NPS across a whole range of service providers, there are a significant number of healthcare providers in and outside the NHS, who have an embedded and achieved sophisticated understanding of Reicheld’s* approach. We shouldn’t dismiss them just because we can’t articulate to a broader audience. Percentages and stars only go so far in meeting service professional needs and the drive for change; so it really depends on how high your aspirations are in creating a customer centric culture in the public sector.

Q) Data collection must be significant, how is it being managed?

The scale is phenomenal; service industries would give their right arm for this amount of customer feedback. Like any new initiative, it has created a vibrant market for innovation in and outside the NHS.

We reflected on establishing a national supplier framework early on, but felt this might confine innovation and supply to larger players. We do need some discipline as this grows however, and a ‘permissive’ approach is not a green light for opportunism or commercial naivety at the expense of the public purse.

Q) How does the FFT impact organisations more widely?

At The Strategic Projects Team we not only see the importance of embedding this tool throughout care settings as a patient feedback tool, it should be seen primarily as an organisational development tool that provides opportunity for leveraging a change within organisations.

We have already been delivering FFT best practice and shared learning within a suite of modules called ‘Towards Service Excellence’, which draw upon current work within our nursing directorates and my experience in other sectors. These modules support a challenged NHS today in taking maximum advantage of all engagement and continuing to build a culture focused on the best possible patient experience throughout their journey.

Ultimately, the NHS Friends and Family Test is the largest patient experience programme in the world. To date it has delivered over

5 million pieces of patient feedback and has all the potential to represent a revolution in patient experience, insight and engagement within the NHS. We have, however, so far only ‘scratched the surface’.

It’s now up to us all to embrace this opportunity to deliver service excellence, as perceived by the ‘customer’. There is huge precedent in what it can bring in productivity and ultimately professional pleasure at all levels, to what the name says we are; a National Health Service.

Andrew MacPherson’s views are his own.

* Fred Reicheld – Co-author of ‘The Ultimate Question’ that outlines Net Promoter insight.

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