There’s a tendency in the NHS to be ruthlessly target-driven. Often, it goes like this: a scandal or a public outcry leads ministers to demand improvement, a 'magic bullet' metric is identified, and providers are made accountable for delivering against targets. Examples are plentiful, as are perverse incentives and unintended outcomes. Take the 48 hour target for GP access: incentivising GPs to provide a high proportion of appointments within two working days simply prompted the withdrawal of advance bookings. Cue jammed phone lines, the practice on auto redial at 8.30am, call back tomorrow or come in and hope for a gap. A target comprehensively hit at the expense of patient care.
If outcry continues to drive a target culture, it is inevitable that the tragedy of Mid Staffordshire will cast a long shadow over what and how we seek to improve. Certainly the Inquiry has already influenced political language: Jeremy Hunt speaking of a 'crisis of care' in some parts of the NHS, Robert Francis himself, during the Inquiry, talking of 'a tsunami of anger' threatening to 'overwhelm' those who fail to engage with and listen to patients and the public. Measuring, understanding and improving the experience of patients is now, and will remain, absolutely centre stage.
The NHS has long been ahead of the curve in measuring experience. It gathers a wealth of qualitative and quantitative information from a wide range of sources, and has had a suite of gold-standard national survey programmes in place for a decade.
The Friends and Family Test represents data collection on a whole new scale. From 1st April 2013, all hospitals in England will be expected to give every discharged adult inpatient or A&E attendee the opportunity to complete the Friends and Family Test. Given a target response rate of 15-20%, this is close to four million responses a year. The key requirement is for one question: 'How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?'. Responses to this question will be collated nationally and acute trusts will be paid under CQUIN arrangements for conducting the test and increasing their response rate within the year. Payments will also be made based on trusts’ results for a similar question in the NHS Staff Survey.
However you look at it, that’s a lot of emphasis on one question. Fred Reichheld, the US customer loyalty consultant responsible for the Net Promoter Score (the inspiration for the test) has described it as 'the ultimate question' and 'the one number you need to grow'.
But is one question enough to evaluate the complex package of transactions and relationships that determine people’s experiences of healthcare? Surely not. Likewise, it’s difficult to see how answers to that question, in isolation, could possibly drive improvement. Knowing whether someone would recommend your service might tell you about their loyalty to or liking of it, but it doesn’t tell you what they liked or disliked or how things could be improved. For that you need more information, more specific questions. You need the capacity to analyse responses and identify themes and priorities and therein lies the gap between the Friends and Family Test as a tool for payment and a tool for improvement.
It follows that the Friends and Family Test cannot, in and of itself, be expected to improve standards of care; indeed we would be naive to imagine that there might be any ‘one number’ that could.
The Department of Health acknowledge this in guidance on the Friends and Family Test. Organisations are encouraged to use follow-up questions and to drive cultural change. These questions are to be determined locally, as is the method for administering the test. This is critical: it’s up to providers to work out how they will use the friends and family test as part of improvement: the onus is on them to decide their own level of engagement.
The best and most ambitious organisations, the ones already trying to live the NHS Plan’s decade-old commitment to 'put patients at the heart of care', will see an opportunity. They will go beyond the requirements of the test, using a range of specific, actionable questions; they will use consistent, robust methods; they will make attentiveness to patient experience part of the organisational culture from ward to board. The worst organisations will simply tick the box.
Chris is Director of Survey Development at the Picker Institute Europe, @ChrisGrahamUK