The friends and family test is much more than a target

A confused, elderly patient in a hospital in the South of England nearly choked to death recently on a plastic token she had been given to “feedback on her experience” of accident and emergency as part of the friends and family test.

When David Cameron announced the friends and family test he said: “Patients are going to be able to answer a simple question: whether they’d want a friend or relative to be treated there.

“By making those answers public we’re going to give everyone a really clear idea of where to get the best care.”

How did it get to this?

I’m not sure that the prime minister envisaged this would lead to A&E departments across the country being filled with large plastic boxes and patients invited to drop tokens in as if it was an upmarket supermarket.

‘A&Es across the country are filled with large plastic boxes and patients invited to drop tokens in as if it was an upmarket supermarket’

How did it come to this? How has such an approach – perhaps useful for choosing between funding guidedogs or the local scout troupe – been allowed to spread across the NHS and now threaten to intrude into general practice and community care?

Blame has to be laid clearly at the door of NHS England and although it might seem to be a minor failure, “token gate” is but one example of multiple ways that the national commissioning body appears, at best, indifferent to the success of the prime minister’s personal vision of a transparent, patient focused NHS.

Not so inclusive

In many hospitals, unless you are an English speaker with no learning disabilities, own a mobile phone and are prepared to spend your own money answering SMS questionnaires, then you will simply not be asked for your test feedback.

It’s not exactly inclusive and risks the NHS merely hearing the views of a middle class, pushy minority.

‘No wonder the CQC refuses to use the A&E friends and family test data as any part of its assessment’

With hundreds of thousands of pounds worth of commissioning for quality and innovation money riding on the results, trusts are still allowed to self-report, decide which forms are “spoiled” and cannot be counted, and choose which patient comments to share.

One doubts this is what Robert Francis meant by bringing more transparency into the NHS.

These are just a few examples of how far the test has been allowed to drift from the prime minister’s original intent, how by leaving “innovative transformation” in the hands of civil servants you get what you might expect.

No wonder the Care Quality Commission refuses to use the A&E friends and family test data as any part of its assessment or quality monitoring.

A major problem is that NHS England just doesn’t seem to understand that it is transparency of data – not just collecting yet more numbers – that is the driver to change.

Rationale for real impact

The rationale for the friends and family test and the way in which it drives change when done properly, is that it tells the public about the NHS – not the other way around. Those hospitals that share all their feedback in an open, transparent way − for example, Queen Elizabeth Hospital in King’s Lynn displays every comment, unedited and in real time on its website − see real impact.

‘Benefits will not be delivered if NHS England continues to shoe-horn the test into an outdated model’

Second, those in Quarry House responsible for delivering this future have simply retreated into their comfort zone of setting targets − this time a response rate, and a ridiculously low one at that.

Done properly, the friends and family test changes attitudes, improves culture and transforms morale, but such benefits will not be delivered if NHS England continues to shoe-horn the test into an outdated model that simply presumes the only way to get improvement is to give trusts commissioning for quality and innovation money to hit yet another reporting target.

One could perhaps forgive these behaviours, as others have noted: you can’t change a government and expect civil servants to instantly change the habits of a lifetime.

Fielding the failings

However there are more serious failings that will delight those that never wanted the test to succeed.

First, NHS England’s refusal − despite repeated advice from external experts − to enforce standardisation of methodology to ensure the data could be trusted and truly competitive.

People use TripAdvisor reviews not because they think the comments are perfect but because they know that at least the same system has been used for each hotel reviewed.

‘There has been zero effort by the NHS to engage the public with the test or to explain to patients how they can use the ratings’

Neither patients nor commissioners can have any such confidence in friends and family data. Indeed 50 per cent of acute trusts employ their own internal teams and run their own unique approach in a blinkered push to meet the central NHS targets − often hitting the target but missing the point.

At the same time there has been zero effort by the NHS to engage the public with the test or to explain to patients how they can use the ratings and reviews like a “TripAdvisor of health” − in the words of the prime minister − to get “a really clear idea of where to get the best care”.

It is such public awareness and the resultant patient pressure that will transform the NHS – without this, Number 10 might as well abandon the test and go back to spending millions of pounds each year on the archaic National Patient Survey.

Despite these omissions and the failure of NHS to make friends and family test the world leading success that it should be, some providers have realised the potential of modern, transparent, real time feedback and are setting the global standard in using patient experience to transform the care they deliver.

Game changer potential

Phil Morley, chief executive of Hull and East Yorkshire Hospitals Trust, describes the impact as “profound, hugely impressive and a game changer”.

He says: “Our patients will have better, more respectful, compassionate care as a result. It is truly amazing.”

The patients in Hull are not alone. Other hospitals have found that using the test to engage staff with patient experience improves morale and delivers a measurable decrease in absenteeism and use of expensive agency staff − directly improving patient care.

Such benefits are now being seen across community providers.

‘It is possible for the test to be so much more than just another target. It could bring the NHS into the 21st century’

Liz Mouland, chief nurse of First Health and Care in Surrey says the test has “become the most powerful lever for everyone to work towards continuous improvements in direct response to patient experience”.

It is possible to do things differently, for the test to be so much more than just another target but rather something that brings the NHS into the 21st century in terms of openly, actively listening to people who use the service and then sharing every word transparently.

When people say the NHS should be “more like John Lewis”, they mean being truly user-centric, honouring staff and continually improving outcomes and efficiency − not creating a risk of choking at the front door of every hospital.

The NHS, its staff and patients deserve the best − no more token efforts please.

Neil Bacon is chief executive of iWantGreatCare, which is a supplier of friends and family test solutions to the NHS