The confusing world of NHS patient feedback
Over the last ten years or so there has been a huge rise in ways in which members of the public can give feedback about their experience of health and care services. This information is one of the ways in which service providers such as hospital trusts, as well as commissioners of these services can get an insight into the quality of services and what needs to improve.
These days there are a range of channels through which people can leave feedback about their experience. These have a variety of purposes:
- Complimenting or complaining about a particular service or experience that will help a service improve.
- Giving a rating that helps other potential service users to decide whether or not to use a particular service
- Creating a dialogue between a ‘customer’ and a provider which might help resolve a problem and build a relationship
- Giving commissioners an insight into how a service is performing through looking at public feedback in the round and comparing this against others.
I think there are 3 main ways in which the opinions and views of people are captured. Some of these rely on the public taking the first step and others reach out to the public.
- Provider organisations all have some way to capture comments and complaints from individuals. These are are specific to the organisation and rely on individual members of the public finding their way to them – they include in house complaints, Friends and Family, PALS services etc.
- Another channel that relies on the public finding their way to them are specialist or stand alone feedback organisations or services such as Care Opinion, Healthwatch Rate and Review (this is NOT a Healthwatch England initiative, but used by some local Healthwatch) and NHS Choices – these rely on their own publicity or commissioners/providers promoting them.
- Then there are National and Local Surveys that pro-actively reach out to the public and try capture a representative sample of peoples experiences of particular services. These may be useful at a national level but their sample sizes are often quite small at a provider level.
Of course it is not quite as neat and tidy as this – for example Friends and Family is provided at an organisation or service level but there is an expectation that providers will pro-actively encourage people to use it.
Different approaches different insights
The situation is further complicated because these mechanisms vary:
Most are service specific – in that they are based on the experience of using a specific service – or even more narrowly the experience of using a service on a particular occasion.
The one that is probably most sophisticated and different is Patient Opinion which starts in a different place – it asks people to tell the story of their issue and from this constructs and connects with various services who may be able to respond.
Care Opinion is interesting because it tries to respond to the whole person rather than just treating someone as though they are the sum of their condition. I think this is particularly important given that local health systems are increasingly trying to develop more integrated and personalised services.
The situation is further complicated by how well signposted feedback services are. Here are examples with web links from three NHS Trusts.
Guys and St Thomas NHS Foundation Trust
This is one click from the main page of the website by clicking on the tab that says ‘your feedback’ one gets access to a range of internal feedback mechanisms.
This is also one click from the main page but a bit harder to find – its on a tab saying ‘Contact Us’ and the feedback form comes after some more administrative information.
Northumbria NHS Foundation Trust
Here the link to feedback is shouting out on the main page – although a bit confusing there are then links to internal complaints, comments and advice on how to get in touch with advocacy services.
None of the above organisations appeared to promote independent channels such as Care Opinion or Healthwatch Rate and Review.
Issues
I think that there is inconsistency with regard to how feedback mechanisms are used across the health system. With different channels of varying utility and a wide variation in terms of how they are promoted. For example the government suggests a variety of ways in which Friends and Family information can be collected:
- There are few constraints on the technology used to collect the data, and a number of different methods would be suitable, for example:
- On-line rating: patients are given information including a web link which they can use to log on, enter a reference number and provide their feedback
- SMS/Text message: patients are given the question at the point of discharge, and are able to text their response (providing an opportunity to send follow-up questions to responders)
- Smart phone apps: patients are given details of the app, including a unique reference number, at the point of discharge
- ‘Voting booth’ kiosks or hand held devices: positioned in the location from which the patient is discharged, with ‘voting’ controlled to allow each patient to only vote once
- Telephone survey – patient is given a freephone number and a unique respondent ID to respond within 48 hours
- Postcard solutions: patients are given a postcard at discharge with an option to complete and return on site or to complete at home and post back.
This variation and the range of different feedback channels makes it harder for the public to decide which one to use and more difficult for providers and commissioners to assess the overall picture of public opinion about services.
It’s interesting that Healthwatch have now entered this area with ‘Rate and Review’. While the logic of this is clear – it brings a systematic way for them and CQC to keep in touch with public concerns it also raises more fundamental questions – in particular how they get the balance between being the provider of a feedback channel at the same time as being responsible for stress testing whether or not a system offers adequate and consistent opportunities for feedback.
I do think that there needs to be some thoughtful work done to consider what good might look like and the respective merits of different feedback systems to ensure that we don’t just gather feedback on individual experience but capture this in a way that helps us to develop more integrated local systems.
What do you think?
And the place of https://www.nhscitizen.org.uk/ ?
Fair point DP – I did wonder about NHS Citizen – and they are in the illustration! However, I think that NHS Citizen tried to be something a bit different – pulling together members of the public with experience and opinions of the NHS and trying to develop a collective view of key issues. You may have a different view?
Best wishes – Mark
I note your observations, Mark. However, no specific mention of NHS Citizen is apparent, IMO. I note the subsequent observation that NHS Citizen ‘have tried’. Sadly that shows the continued ‘institutional’ and ‘structural’ mindsets that continues to champion their perceptions over the individual realities of personal journeys. It is not satisfactory for individuals to have to risk total public disclosure in order to obtain the simplicity of duty of care and safeguarding. Noting that Healthwatch and NHS Citizen staff have dominated the debate with the support of partnership institutions under the guise of engagement. A narrative of genuine contact, connection and communication is not apparent to many who are on lonely health and social journeys.
Hi, Mark
You wrote not long ago:
”markgamsu PERMALINK*
September 5, 2016 08:25
Thanks for your comment. I do not usually accept anonymous comments- but given that you have taken to the time to comment I will respond. If you do decide to comment further please add your name.”
Have you changed your policy?
Regards
AGM
https://gather.nhscitizen.org.uk/members/doepublic/
Thanks Hilton – appreciated – Mark
You gave an interesting presentation to Anu Singh’s Workshops about the future of Citizen on 12 Sept.
What’s your impression of the paper being presented to the NHSE Board on 29th Sept, please?
https://www.england.nhs.uk/wp-content/uploads/2016/09/item-7-29-09-2016.pdf
Regards
[ Anu Singh was appointed as NHS England – Director PPPI, starting in Jan this year.]
Background point 17 implies on-line access. This was not the case. Only one of the threads was accessible (viewable) , but limited interaction. Clearly an agenda of perceptions exists. Accessibility being a primary deficit.
Thanks I’ll have a look at it
NHSE Citizen-Gather is to be relaunched, with a much strengthened contribution from rank and file P&P:
NHS ENGLAND BOARD MEETING 29/09/16
Purpose of Paper:
To summarise the changes to NHS Citizen since the November 2015 Citizens Assembly,and set out the proposed new approach for delivery.
https://www.england.nhs.uk/wp-content/uploads/2016/09/item-7-29-09-2016.pdf
Thanks Aanon for placing the document in the public domain. Clearly open access was not policy during the workshops,. Confirming the communication deficit that exists.
Hi Mark
Thanks for this really thoughtful post. And I agree: there is much confusion, on the part of patients, staff and policy makers alike.
At Patient Opinion we try to avoid getting confused by staying focused on the citizen: someone to whom services are accountable, who is connected in community with others, and who has agency and may even want to be active in helping services learn and change.
I have blogged about this previously: https://www.patientopinion.org.uk/blogposts/240/being-citizen-centred.
Of course, citizens interacting with the NHS in this way mainly happens face-to-face. But of all the services you mention, none other than Patient Opinion enable public online dialogue between the feedback author, providers, commissioners and local healthwatch.
I’d support your call for more work on considering what good looks like, and the pros and cons of various approaches. If we can learn together, we can continue to imagine and build better feedback systems that serve patients and staff, and perhaps even reduce the confusion.
Cheers James – good to hear from you. One further advantages of independent services like Patient Opinion is precisely that – you avoid having to bend your behaviour to allow for corporate anxieties. In my personal view NHS provider services should actively promote use of Patient Opinion for the reason I have just given and for those that you address in your comment above.
Best Mark
Mark, just to clarify, your link in the article to Healthwatch’s Rate and Review service is for Healthwatch Torbay, and not Healthwatch England as you claim towards the end.
In fact, the state of play within Healthwatch also adds a layer of complexity – each local Healthwatch office (and I work for both HW Bradford and HW Leeds) runs independently and can therefore choose their own method for data collection and feedback. Some use the “Rate and Review” Feedback Centre from LHM to encourage the general public to give feedback directly, while others focus on face to face encounters at outreach events, surveys for specific projects, or ‘Enter and View’ visits to services, which are similar to CQC inspections (but less formal).
All of us in local HW teams constantly try to respond to that issue you raise – about the balance between providing a feedback channel and ensuring that feedback channels are appropriate and robust.
An interesting article and a helpful review of the current state of play. It is a confusing and multi-layered thing, but we each work with the opportunities we have to ensure that patient feedback is included and a critical part of decision making at every level.
Many thanks Rose – particularly for drawing attention to the complex world that local Healthwatch have to navigate. You are right about the link going to HW Torbay rather than Healthwatch England – I had a quick look on Google and could not spot a direct link to Healthwatch England – although I think they did develop it.
Technically the Feedback Centre was developed by a couple of Local Healthwatch offices but it’s now a separate, corporate product sold to other Local HW offices at price. Healthwatch England has a different, distinct role to try and pull a coherent message from the research and engagement conducted at the local level, and don’t directly receive feedback from the general public (usually). Does this help?
Hi Rose thanks for clarifying this – I did not realise that the Feedback Centre was developed by a couple of local Healthwatch – cheers Mark
Thanks Mark
It seems that collecting feedback on the NHS has become something of cottage industry in its own right. From a learning perspective, I wonder how much data is gathered because this is a required thing,as contrasted with that which elicited deliberatey to help to change something? It would be interesting to see evidence of where feedback actually results eg in some service development or modification.
On the other hand I imagine that there is a significant therapeutic aspect to offering and using feedback channels. When a friend of mine’s father died in somewhat distressing circumstances, she wanted to feedback some of the things the hospital could have done better. In this case, the people she talked to kept directing her down the “Complaints” channel – which is emphatically not what she wanted to do. Eventually she found someone who would listen to her, and that was fine – or at least, probably the best outcome possible.
Mike
Hi Mike
Have a look at Patient Opinion. You’ll see people giving feedback in exactly the way you describe for your friend. You’ll also see learning and change resulting from the feedback in more-or-less real time.
Here’s an example from just last week: https://www.patientopinion.org.uk/opinions/314102
Hope that’s useful.
James
This overview misses the deep divide in power, interest and skills to bridge the gap between how people live their lives and what the statutory sector offers in services and support. There are approaches like user-driven commissioning which seek to address by building on user-driven action: people with lived experience looking inwards to identify that stand in the way (and vice Versace promote) feeling good about themselves and any ‘condition at stake BEFORE becoming trained as co-commissioners with a set percentage in deciding on the winning bidder through contract award and ongoing management – co-production over months. Don’t know why USER-LED approaches (not proxies) do not seem be promoted in such forums even if very few statutory bodies come on board to take involvement seriously and stop the fragmentation described in the blog.
A fair point Bernd – although I thought that a lot of what I write about on this blog does seek to promote citizen led approaches – but you may disagree!
This particular piece deliberately focusses on commenting on the current channels for public feedback. I do agree that there are real issues with regard to power which I think all feedback mechanisms struggle with to varying degrees.
Although I think some of the ways that individual NHS providers (such as those providing services to people with acute mental health problems or learning disabilities) have sought to support people to leave their own stories about their experiences are worth recognising.
Nonetheless there is a much wider issue – these channels are very much focussed on individual experiences and a number assume access to digital technology. See the work of the Tinder Foundation on the digital divide – http://www.tinderfoundation.org/sites/default/files/digitalnation-2015-webb.pdf
While I think that mechanisms for individuals to leave stories about their experience are helpful I think that real meaningful change comes from approaches that are built on long term co-produced relationships.
Thanks Mark, interesting and useful article. Another raft of structures and organisations which give patients an opportunity to feed back their experiences and engage with the NHS is patient participation groups (PPGs) – at GP, CCG and wider NHS level, and as lay members on CCG Boards, Clinical Senates etc and other forms of Patient Leadership/ Patient Expert opportunities.I know this is a wider role – shaping services (with varying degrees of effectiveness I’m sure) rather than chanelling specific feedback of their own experience, and I recognise it is often provider-led or even a statutory requirement – but I expect there is potenital for individual feedback through these channels. And greater awareness of the various structures and opportunities which encourage patient voice and influence has got to be a good thing, and might unlock potential for a more coherent approach.
I’ve got a lot of time for Patient Opinion and tried, in my own small way, to promote its use in the hospital where I am a volunteer (Good Hope, HEFT). The then MD was a fan. However several changes in management has meant that the impetus has been lost. Responses are left to a very busy PALS who are quick to accept praise but slow to respond, if at all, to complaints. And a change in behaviour as a result of feedback is virtually non-existent.
Not the fault of Patient Opinion of course but it does lead to the unsurprising conclusion that senior management must engage seriously with whatever complaints mechanism you end up with. Otherwise you will end up with a situation where – as often seen on Twitter – comms department trumpet a ‘good’ response but ignore any negatives.
With regard to Helen’s post, in my trust at least, the patient has a voice – the governors. But it is difficult to contact them – no public emails, they don’t visit hospitals on an ad hoc basis (indeed I think they are not allowed to) and are always members of the local ‘great and good’, not typical patients. So I think the structures Helen lists are likely to be ineffective.
Change needs to come from within but I don’t see any evidence that the NHS is serious about complaints.
You hit the nail on the head in your last sentence. Gathering patient feedback is the first step in improving services and there has been serious improvements in this at least. There is a also much gathering of evidence from NHS staff through regular staff surveys. I speak as one who has filled in many of these through gritted teeth, knowing that real change is unlikely to occur.
The Office of Fair Trading published a paper to show what good looked like back in April ’11
Big surprise it doesn’t look like anything described above.
Feedback systems which the patient needs to seek out to use only collect extremes of opinion. True for TripAdvisor and true for the rest.
And… Feedback collected in person is so positively biased that it becomes vanilla giving a trust nothing of value to work with.
Generally there are too many barriers to people leaving feedback, finding a website, entering a pin number, or walking to a post box.
Here is the link: http://webarchive.nationalarchives.gov.uk/20140402142426/http:/www.oft.gov.uk/shared_oft/reports/consumer_protection/oft1321.pdf
Cheers Mark – thanks for the link in particular – will check it out – best wishes Mark
You’re welcome Mark, and please don’t hesitate to ask if you want to try using a ‘next generation’ feedback solution.
The TripAdvisor type solutions you write about simply don’t give hospitals or GP surgeries what they need, and either directly or indirectly they’re expensive.
Hootvox can do much more than any other system you’ve looked at here.
All the best, Mark
@ricmmorris September 25, 2016
I agree strongly with your empirical evidence :
” the patient has a voice – the governors. But it is difficult to contact them – no public emails,”
On our Hosp Foundation Trust, the elected CoGs have a policy of NOT having direct contact with their ‘electorate’, never mind any other P&P.
” ..and are always members of the local ‘great and good’, not typical patients ”
It’s almost the opposite with ‘our’ CoGs.
The Parliamentary Constituency elected CoGs are voted on by only a tiny fraction of the Registered electorate . NOT because of apathy on behalf of those who are entitled to vote in ballots for :
Parish / Neighbourhood, ‘councils’
Local & County Councils
General elections
MEPs
Referendums
But because they’ve been disenfranchised. They can NOT vote for their CoG.
To do that one has to be additionally registered in the exclusive club of the Members of the Trust. A club which we ALL pay for running, but unlike the rest of the democratic process, have to apply to join, over and above.
Because this electorate is so small, and the turnout a minor part of that small %, these seats have been captured by very narrow sectional interests, not generally health or politically driven.
Those elected fall into two categories, from my long observations,
Those few who see it as a fast track to higher things
Those who have little idea of why thy’re there – never ask questions or contribute other than to stick their hands up as instructed.
Even the Chair is overruled and marginalised by the Chief Officer
”So I think the structures Helen lists are likely to be ineffective.”
They ARE ineffective
”Change needs to come from within”
History teaches us that those who hold power never give it up, even when asked politely.
We need a National-NHS-Public Voice, under our control, and responsible to the P&P who own our NHS, or did, and will again.
Unity is Strength.
The lights are going out at NHS Citizen. It was a bold but ultimately flawed project predicated on the idea that large numbers of people have a burning desire to be involved. They don’t. Involvement is not an occupation.
Collecting feedback where people use services and going where they go to find out what they think are clearly important, but a dedicated online hub was never going to work for all sorts of reasons, the most obvious of which is that the “NHS citizen” they had in mind doesn’t exist.
Hi Julian – I think your comment here has prompted NHS England to respond as follows:
//platform.twitter.com/widgets.js
@Hilton Mayston October 2, 2016 16:13
Thanks Aanon for placing the document in the public domain. Clearly open access was not policy during the workshops,. Confirming the communication deficit that exists.
————
My pleasure
Regards
Aan T on / Aanton Mann,
A few comments: Are there too many different channels for patients & the public to provide feedback to the NHS? How do we know which to use? Which one will be best for influencing the organisation? The pathway taken by a patient will pass through several different sectors of the care services and we often don’t know which is which. Most organisations will only look at comments that relate to their service. so plenty of opportunities for gaps.
Another point is that if us patients make a comment as part of the feedback process we would also like a swift response as meaningful feedback on what action has been taken and if none an explanation as to why. All too often all the feedback we get is a bland statement like ‘learning has happened’.
What is needed is a single body, independent, local (county or CCG, or even STP) that collates and analyses all the various forms of feedback (complaints, PALS, FFT, local surveys, CQC reports as well as adverse incidents & SUI etc) and reports on themes & local hotspots etc. They should show trends over time so we can see progress and improvements.
so we need feedback at the individual level but also at the wider community level.
Thanks Mark, This is a really helpful summary of something which has taken me a while to get my head around. Whist there is probably some value in a diverse range of options and modalities, it does mean that at an organisational level it can be difficult to know which to promote and actively support.
We have recently started using care opinion (which is how patient opinion has recently rebranded). The “little loops” from inputter to local responder allow for a meaningful dialogue between someone who has used the service and someone in a local position able to address issues raised, as well as ensuring staff get feedback about when things go well. The collation and analysis function also looks potentially helpful.
You have not dwelt on local Service User led feedback collection which is also likely to have a different flavour and local impact?
A concern with multiplicity of approach’s is feedback fatigue. I recently battled through a complex feedback form about a colleague’s development only for another lengthy questionnaire to pop up in the screen asking for feedback on the questionnaire. Too much is too much! and will thwart the value to be gained
Thanks Helen – I do think that Care Opinion continues to have a lot to offer and I am disappointed how many NHS trusts seem to have little interest in using it to its fullest extent. I am interested in the point you make about local service user led feedback collection – can you expand on what you mean by that? With thanks Mark