Despite what we read in the papers and the furore which is often created by NHS reform, it is our own personal experience, or that of those we care about, which is most powerful in shaping perceptions of the NHS.
Most people have a positive experience of NHS treatment and care, but it is important to recognise that some do not. The extent to which this can be addressed and improved will be an important test of the new focus on outcomes. Remember: a key criticism of targets was that they could divert attention away from what mattered most to patients, sometimes compromising patient experience in the process.
The patient experience gap
Delivering an improvement in experience from a relatively high baseline will not be easy. The Francis Inquiry has revealed in the starkest terms how care can go wrong and how this manifests itself in poor experience. At a less horrific but nonetheless significant level, detailed patient experience surveys have shown the gaps that can occur in patient care. They have also exposed the variations in the quality of experience reported by patients cared for by different organisations: if many providers can get it right, how can others get it so wrong?
It is also clear that the gap in patient experience is not simply one between high and poor performing providers. Some hospitals which are world class research and teaching institutions, and which are often seen as a jewel in the crown of the NHS, also have a patient experience problem: clinical excellence does not always equate to compassion or good communication skills.
The financial climate in the NHS will also not make things easier. The RCN’s claims about loss of nursing posts may have been disputed by the Department of Health, but what is clear is that pressures on the frontline are growing. The domain lead will need to keep patient experience on the agenda in a way which makes it more difficult for frontline staff to deprioritise it.
Measuring what and for what purpose?
Patient experience can be measured in a variety of ways, each of which can have different benefits, ranging from capturing the outcome (important for evaluating progress on Domain 4), to enabling patient choice, or ensuring that patient feedback is utilised in designing service improvements. Each is important and championing each of these different methods should be an early priority for the domain lead.
What is also clear is that the NHS will need to move beyond its existing methods of capturing experience. The inpatient survey, currently administered by the Care Quality Commission, provides some interesting feedback on controversial issues such as single sex accommodation or hospital food, but – capturing the views of 70,000 patients across the NHS – it fails to provide the granularity required to inform improvement at the service line. It needs to be supplemented or replaced by service or disease-specific surveys, such as those for cancer or end of life care, which provide more meaningful information to patients and which are harder for providers to avoid accountability for.
The recent announcement of a plan to introduce a ‘friends and family test’ (asking a patient or carer whether they would recommend hospital wards, accident and emergency units to a friend or relative based on their treatment) will provide a useful comparator. However, its impact could be maximised by ensuring that results can be disaggregated to service levels (it is of limited use to a patient needing a hip replacement to know whether a diabetes patient would recommend the hospital) and more detailed information on patient experience is also collected (the patient might wish to know why –or why not – a patient would recommend a service).
The detail will be particularly important if the commitment to integration – enshrined in law – is to be translated into reality. Evidence from patient experience surveys shows that patients often experience poorer care at the points in their pathway which involve hand-offs (surely they should be referred to as ‘hand-ons’?) between one organisation or team and another. Collecting detailed information – and acting upon it – could be a powerful way of measuring and improving an otherwise intangible concept.
Paying for measurement
Measuring patients’ experience is not a cheap task, nor is it one which can simply be devolved to local providers or commissioners (doing so means that the results are rarely timely or comparable). The domain lead will need to convince the NHS Commissioning Board and the Department of Health to invest in measurement at a time when money is tight and the presumption is that activity should be locally driven and delivered.
One way to resource the measurement of patient experience in a sustainable way would be to mandate participation in surveys through the model contract and refine the national-level CQUIN on patient experience so that it could be measured at the service level and be more reflective of the broader patient experience than the current measure. High performers would achieve full payment, whereas the tariff withheld from low performers would effectively help pay for the survey itself.
Action as well as measurement
Of course, all of this will be of limited value if the measurement is not translated into action, and ultimately this is where the focus should lie for the lead for Domain 4.
Part of the challenge will be to persuade commissioners, and through them providers, to take the findings seriously and act upon them. Otherwise the collective voice of patients, captured through the systematic measurement of their experience, will be wasted. One hospital, for example, was heard to respond to the findings of the cancer patient experience survey: “how do I know that the patients who responded weren’t lying?” As with the other domains, diplomacy mixed with steel will be a vital quality for the Domain 4 lead.
We now know more about the determinants of good quality patient experience – high quality written information; good communication skills; adopting a personalised approach to caring for a patient rather than treating them as simply part of a wider group; and approaching them as a partner in care rather than a passive recipient of it – but we still know too little about how to lead change, turning a poor performer into a good one. Identifying the gold dust and using the new levers to spread it will be some challenge.
Read more about what we think about the NHS Outcomes Framework:
And look out for what we have to say on Domain 5.