Policies aren't being realised in areas most important to patients

The dust is just starting to settle on a memorable and surprising general election. 

The headline message is well rehearsed: over a period of months and years, the polls got it wrong. Spectacularly wrong. 

‘We have an opportunity to take stock of the quality of NHS services’

Instead of a photo finish and the delicate negotiation of a new coalition government, the ballot returned a clear parliamentary majority – and attention now turns to policies and plans for the next five years. 

As a result, the new government arrives with an existing position and direction: the Conservatives have already endorsed the NHS Five Year Forward View, so there is a certain sense of business as usual.

This means we have an opportunity to take stock of the quality of NHS services and reflect on aspirations for the next five years.

The initial focus has, unsurprisingly, been on the headline commitments around funding and staffing levels, but there’s another job to be done around patient experience.

Survey results

Before the election all the major parties spoke of their support of the idea of person centred care: services should be designed around patients. 

This is an accepted matter of consensus. Yet survey results up to 2013 show little change in people’s experiences of care. 

Published today, the results of the 2014 NHS inpatient survey – the 12th of its kind since 2002 – provide a contemporary view of what it’s like to be a patient in hospital and allow us to look at trends in performance across a broad range of issues. 

‘There have been massive strides towards the elimination of mixed sex accommodation in hospitals’

Some trends are encouraging. 

Since the survey started, there have been massive strides towards the elimination of mixed sex accommodation in hospitals: in 2014 only 7 per cent stayed on a mixed sex ward; and less than half of the 22 per cent who said this in 2004. 

Wards are, in the view of patients, much cleaner: 69 per cent of patients rated wards as clean last year compared to 54 per cent in 2004. 

And patients are far more likely to receive copies of letters between their GP and hospital consultants (64 per cent in 2013 vs 35 per cent in 2005 when the question was first asked – although, sadly, they’re only a little more likely to be able to understand these letters – 76 per cent in 2013 vs 73 per cent when we first asked this in 2009). 

Much of these improvements can be traced to specific policy initiatives. 

Patients’ top picks

But whilst national policies have driven significant and sustained improvement in some areas, it’s not clear that the same improvements have been realised in the areas most important to patients. 

There’s plenty of well established evidence about the constituent features of person centred care – the “Picker Principles” are a well known example, describing eight domains that matter to patients. 

Three areas of interpersonal care stand out as being especially salient to patients: communication, involvement and coordination. 

‘Communication, involvement and coordination stand out as being especially salient to patients’

These all describe the “relational” process of care (the human interactions with health professionals) as opposed to the “transactional” components (how care is accessed and in what environment, the interventions performed, and so on). 

This distinction between the relational and transactional components of care is important because the majority of national initiatives (with some exceptions, notable including the recent 6Cs initiative are focused on the transactional side – and this, as described above, is where improvements have been realised. 

By contrast, communication, involvement, and coordination have improved only marginally – if at all:

• 56 per cent are “definitely” involved as much as they want in last year compared to 52 per cent in 2004.
• 68 per cent in 2014 said they “always” got understandable answers from doctors when they had important questions, compared to 65 per cent in 2004.
• Only 39 per cent in 2014 were “completely” told about medication side effects to watch for after leaving hospital – which remains the same as it was in 2004.  Given that adverse drug events are a major cause of potentially avoidable readmissions, this suggests significant room for improvement on the co-ordination of care. 

These figures suggest that there has been some improvement in person centred care over the last decade but the pace of change is slow in the areas that matter most to patients.

National focus

Now, it’s probably fair to say that these interpersonal factors are harder to change than some of the more mechanistic elements: removing mixed sex wards, improving cleanliness, and ensuring patients are copied to letters may have involved no small amount of political will – not to mention expenditure – but they are low hanging fruit compared to changing the way professionals interact with their patients on a day to day basis. 

Consequently, no one is arguing that there is a quick fix to be found – but review of what has and hasn’t changed in recent years firmly implies that committed national focus is needed if we are to see nation-wide improvements in person centred care.

‘Nationally, a five percentage point improvement on the results seems achievable’ 

As a new Parliament commences and we take stock of where we are and where we want to get to, it is timely to look at the figures above and ask what results we want and expect to see by 2020. 

Nationally, a five percentage point improvement on each of the results quoted above seems achievable: that should be the minimum. 

A stretch target might be double that. But today’s results are not only national: data is also available for every NHS acute trust providing inpatient services and we invite each provider to look at their own results, set their own 2020 aspirations, and challenge themselves to provide better interpersonal care with each passing year.

Chris Graham is director of research and policy for Picker Institute Europe