24 October 2011

After the damning Care Quality Commission report into NHS care of the elderly, I should probably just be glad that my mother emerged alive from her recent brush with the local hospital. But, since we are supposed to live in the era of what has been called "tripadvisor" government, I decided to try to give some feedback on her experience with the NHS. It's not as easy as it should be.

The first thing to note – and maybe not without justification after the report this week about GP’s striking off stroppy patients – is how reluctant my mother was to give feedback.  She was a bit resassured by the promise of anonymity (though you need to give your email – so will it really stay anonymous?). But her real fear was that the hospital would get its own back next time she ended up in their clutches if you dared to criticise.

Other people may share that fear. For what is notable is how few comments people post about their experience. In three and a half years the hospital where my mother was treated has only had 54 comments – running at about 15 a year. Contrast that with the real “tripadvisor” where a hotel I reviewed in Copenhagen had almost 700 in 8 years – almost 6 times as many. Alternatively it may just be that the user profile of a south coast hospital and people who are comfortable sharing their thoughts online barely overlap.

But maybe I should be reassured that 4/5 of people recommended the hospital my mother was in. But it may not be a representative selection. On the Trust’s website, there is a choice between making a complaint – by email or phone (to the patient liaison service who point the complaint at the customer relations department) and offering “positive feedback” which takes you to the NHS Choices site. So complaints are siphoned off into secrecy while only positive feedback is invited publicly. The trust does say it reports on complaints in its annual report – but it doesn’t seem to be worth a single freestanding section among all the pictures of smiley nurses and patients and if it is there, it defied my attempts to find it.

Nevertheless some people do persevere to give positive – and negative - feedback. But the questions are frustratingly superficial.

They start with a binary rating – were you satisfied or not? In any complex operation a simple yes/no is unlikely to suffice. We ended up saying “no view” because our answer was good on some things, poor on others. Three stars, not five, nor none. Would that be so hard?

The prompted questions themselves give an interesting insight into NHS priorities. Was it clean (on a six point scale)? Did the staff work together well? Were you involved in decisions about your care? Were you treated with dignity and respect? And was the hospital meeting the commitment on single-sex wards. Nothing about the quality of care.  The efficiency of the operation. And impossible to differentiate between wards; services and different members of staff. One of the things you realise in hospital is that there is huge amounts of variation within an institution – one ward good, another substandard.  One nurse caring, another indifferent. Useful feedback would pick that up.

Which puts the entire burden on the comment section – divided between “what I liked” and “what could be improved”. But comments of that sort are hard to pick up and pull into a comparative rating.

Some feedback on feedback

Make it clear that feedback is welcome – both positive and negative.

Add some categories on quality of care and how well run the hospital appeared to be.

Allow differentiation between wards and services (and capture all the ones the patient used – my mother was in A and E, coronary care, ortho-geriatric and used the phsysiotherapy and the occupational therapy – and has different views on all of them).

Finally – make it easy for the sort of people who are patients to give feedback. When my mother was treated privately in the same hospital she was given a paper feedback form: not on the NHS.  Which is a shame – because it meant they might have missed her major comment – that the NHS treatment was far better than the care she received privately.


Hi Jill, I'm one of the team running Patient Opinion (www.patientopinion.org.uk).
You've raised a whole host of interesting and significant issues in this post, and many are things we've struggled with - and still struggle with - in our 7 years experience of providing an online feedback platform for health services.
(For background, Patient Opinion is a non-profit social enterprise. We've been building and learning about online feedback for health services since 2005.)
Certainly, we know that many people don't know they can give feedback online, or are scared to, or feel it would be pointless. We've designed Patient Opinion specifically to address these concerns - you can see which postings are read, which have responses, and which have led to a change. Soon we'll begin to show which providers are good at listening to patients and carers, and which are not.
But still, our biggest challenge is ensuring more people are aware of and use Patient Opinion.
You highlight the tensions around asking specific questions - which may or may not reflect people's actual concerns. Over the years we've come to the view that the power of feedback to produce real change is precisely in the telling and hearing of a story, rather than in the aggregation of numbers. People's stories often tell you not only what was poor, but how it could be better - and they motivate people too.
We don't think online feedback is - or should be - about simply collecting data. We think there is a much bigger prize at stake, which is about changing the way people relate to their local services, and the culture of services themselves. In some places, we've started to see some of that happen.
And just on your final point - we receive feedback online, by phone and by post as well (and soon digital TV too) , so there are lots of ways people can contribute their experiences - if they know about us.

Thanks very much for this. I wasn't aware of Patient Opinion and it seems a very good initiative. shame it is not explicitly publicised to patients.

I think there is a case for a better mix of quantitative and qualitative ratings. so I would have a few moe explicit questions - which might then generate tables which can have a powerful effectin driving up standards - and would be useful for Trust boards - but retain the story telling piece to give colour on actual experience and capture the things that any set of formal questions will inevitably miss.

as an addendum; just checked PO website. the hospital where my mother was treated has just 6 comments; most recent "almost two years ago"; only one response.

so need to find a way to get traction.

Feedback in public services is such an interesting topic, and yet it rarely gets the attention it deserves when it comes to policy design, which nearly always seems to focus on some kind of systemic change.

For example, would there need to be more patient choice and competition between hospitals as a driver for improving standards if those standards were instead constantly driven upwards by rigorous assessment of, and reaction to, public feedback?

Hopefully the visibility of services like Patient Opinion will mean that kind of pressure for change becomes more powerful in future.

PS. I've written some more <a href="http://www.edemocracyblog.com/political-blog/making-use-of-feedback-on-p... rel="nofollow">about feedback in public services here</a>, looking at the relationship between feedback, policy and implementation.

There is a lot to be said for quantitative measures of public service quality - but collecting such things online, from an inevitably selective sample of users, is fraught with difficulty.
That's before you even consider the risk of service providers manipulating the results by entering spurious data.
One (partial) solution to this is to create metrics not from "user ratings" but from the way organisations respond to feedback. For exaple, on Patient Opinion we are beginning to show metrics like how many staff are listening? How many responses does this organisation make? How many improvements?
Richard makes some really good points above - and there is clearly some potential in "healthy competition" between hospitals etc. But again, we would take a slightly different focus - rather than inform choice, can user feedback in itself directly engender change?

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