Serious funding challenges

The Conservatives’ promise to protect overall NHS funding “in real terms” was an essential part of their election policy. It effectively neutralised the NHS as an issue during the election. But, as any economist will have noticed, the promise to protect funding was never going to be a promise to leave the NHS alone. Given the increasing demands on the NHS from an ageing population and the rising costs of drugs, merely keeping the overall budget constant in real terms will require some serious cuts in parts of the NHS budget. One of the most surprising pledges by the new Government is to pay for all new cancer drugs – a commitment which is likely to require deep cuts elsewhere.

Bureaucracy will be challenged more than it’s ever been

The last Government claimed to see “bureaucracy” as getting in the way of delivering an efficient health service, and the new Government is no different. However the Conservatives characterise Labour’s administration as “top-down, bureaucratic mismanagement”, and they are promising to cut administrative costs much more deeply than Labour dared to promise. The Conservative manifesto speaks of “a culture where ticking boxes is more important than giving patients the treatment they need”.

The coalition’s Programme for Government says, “We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line”. This is a terrifically ambitious pledge and will be painful to achieve.

Targets will be abandoned

Many staff will be happy that targets are being abandoned by the new Government, who plan to focus on results “which really matter” such as survival rates and infection rates, rather than what patients moan about most such as waiting times. These health outcomes should be easier to measure and monitor, and this in turn will reduce paperwork and save some costs.

GP contracts will be renegotiated

Some are forecasting a “long and bloody battle” with GPs as the new Government intends to force GPs to take back responsibility for providing care at weekends and in evenings, which in effect means refusing to honour Labour’s 2004 contract with GPs that allowed them to opt out of out-of-hours care. The intention is good – to improve standards of out-of-hours care so that it is not provided by medics who are unfamiliar with the patient, and of course to improve patient satisfaction in the process. But to provide such care GPs will need to co-operate more as part of local groups, losing some autonomy, and making lifestyle compromises in the process, something they may not do happily.

Patient satisfaction will be improved by the carrot not the stick

Reading between the lines of previous years of policy statements, Andrew Lansley seems to be just as committed to patient satisfaction as Andy Burnham has been over the last few years. And in keeping with this, the Con-Lib Programme for Government contains a pledge to “enable patients to rate hospitals and doctors according to the quality of care they received”, as well as a commitment to transparency about performance and mistakes.

However the emphasis is likely to be less on meeting patient satisfaction targets, and more on allowing patient satisfaction to speak for itself by allowing competition to reward those who deliver higher satisfaction levels. Promises include “the right to choose your GP, hospital and even the consultant responsible for your care”, something that will make patient satisfaction important but without imposing targets.

What it means for us

At PatientPulse we can see continuing opportunities for our service to meet the needs of the new NHS. Our service allows GP practices and PCTs to save administrative time and money by automating their collection of patient satisfaction data and getting rid of time-consuming and fiddly paper surveys. And PatientPulse works out an awful lot cheaper than paying for the administrative time to run a paper survey, whilst offering the easy-to-use reports which keep practices on the right track to grow patient satisfaction, and ultimately to grow patient numbers in the more competitive world where resources will be spread more thinly.

A survey by the Care Quality Commission has concluded that increases in outpatient satisfaction will be sustainable even after expected cuts in budgets in 2011.

The survey reveals that patients are waiting less than six weeks to get an outpatient appointment, and are rarely delayed for longer than 15 minutes on the day. Further, patients are reporting that hospitals are cleaner and more welcoming places to visit.

The biggest shift in satisfaction scores however can be attributed to the manner in which healthcare professionals are treating patients. Patient led care is becoming ingrained in the health service, resulting in patients that are happier with the care they are receiving from NHS staff. Patients feel more involved in their treatment decisions, and their opinions are increasingly treated with consideration and respect. Good communication plays an essential role in patient satisfaction.

Health minister Ann Keen said: ‘NHS staff should be pleased that 95% of outpatients rate their overall care as good, very good or excellent. This is a testament to their hard work and dedication.’
With the improvements being attributed to greater professionalism and changes in practice, the results should be more sustainable.

However public perceptions of the healthcare service can be easily dented by high profile failures, such as those highlighted by the independent inquiry into poor practice at the Mid Staffordshire NHS Trust.

But the public and patients can be very different groups. With an increased focus on patients’ satisfaction, healthcare professionals are delivering a better quality of care at the point of experience – and that’s what really matters.

In the last couple of weeks we ran a survey of 125 GP practices, with the co-operation of First Practice Management. We wanted to find out from the horse’s mouth what methods of measuring patient satisfaction were currently being used, what GP practices were considering for the future, and how much importance they placed on measuring patient satisfaction.

The results were really rather interesting.

75% of practices still using their own paper survey – but why?

A high proportion of GP practices still operate (and plan to continue operating) their own paper survey – in addition to the national postal GP Patient Survey run by the Dept of Health. 75% of practices said they did this currently, with a further 11% considering doing it in the future (the full table of results is further down this blog post).

This surprised us since there is no longer a need to do this to qualify for QOF funding. The new QOF rules for 2009/10 don’t put any weight on carrying out a survey because the national GP Patient Survey will now cover all practices. Where approx. £7,000 of QOF funding for a typical surgery used to rely upon administering a survey, and acting upon its results, this is no longer the case.

In addition, because the new GP Patient Survey will now run quarterly rather than annually it really does look like running your own paper survey is likely to duplicate effort.

So are practice-level surveys dead?

If the financial incentives for running your own survey are now gone, what’s the point of doing it?

We asked GP practices what were the reasons driving them to measure satisfaction, and only 34% said that direct financial incentives such as those in the QOF were important. A higher percentage – 45% – said that giving their staff visibility of patients’ views was an important reason. This suggests there still remains some value in it to practices.

Here’s the full table showing what practices thought were good reasons for measuring patient satisfaction:

In fact, we think that the QOF changes are great for practices. They mean that practices no longer have to follow strict rules about carrying out surveys that are representative of their patients – so they are free to introduce new methods such as online & mobile methods. But practices still have a strong interest in finding out what their patients think, as their scores in the GP Patient Survey still count towards QOF funding. What practices can do is complement the GP Patient Survey with different ways of getting feedback from patients – more ‘real time’ feedback, which they can review on a weekly or monthly basis to track improvements, and more qualitative feedback which is not captured by the GPPS. Importantly, practices can avoid the administrative burdens put upon them by paper surveys and concentrate on methods which are much less administratively heavy.

Online feedback expected to grow

Here’s the full table of results showing what methods of patient feedback gathering practices currently use, and are considering:

You’ll notice that just 25% of GP practices use online methods of capturing patient feedback and measuring satisfaction, but that 34% are considering this for the future – a growth area. Music to our ears!

If you’re one of the GP practices currently doing a paper survey, consider ditching it for something that takes up less administrative time, and that offers you ‘real time’ information and qualitative patient views.

Download Survey press release and data tables

So it seems that up to 10% of individual NHS Trusts’ funding could depend on patient satisfaction scores! This was the announcement made back in December by the Health Secretary Andy Burnham, as he sketched his vision for the NHS over the coming 5 years (assuming he’s still in government after the election, of course).

You might expect Patient Pulse to be strongly in favour of this development – after all, we want the healthcare sector to take notice of patient satisfaction. It’s our business. And we believe that measuring patient satisfaction, and putting in place incentives to improve it, leads to happier patients.

However we’re not in favour of allocating health care resources on this scale (a massive 10% of budgets for goodness sake!) on the basis of patient satisfaction.

Here are the two biggest reasons why we’re not in favour.

10% is too much and will divert resources from struggling hospitals

If a hospital or trust is struggling to give good patient care, to take away as much as 10% of funding based on a low patient satisfaction score is likely to lead to the deterioration of care rather than improvement. In other words, it’s counter productive. 10% of funding is likely to make the difference between a hospital being well equipped to give good care and being poorly equipped. Financial incentives are important and can drive behaviour, but we’d argue for a direct incentive for particular staff who can make the difference to patients – in the form of variable staff bonuses, particularly focused on the management layer, to drive patient-friendly behaviour and processes rather than the blunt instrument of withdrawing overall funding, which risks reducing a hospital’s ability to carry out vital patient care tasks.

Comparing patient satisfaction across hospitals is an unreliable way to allocate funds

Secondly, we agree with the NHS Confederation (which represents NHS trusts) who have rightly commented on how “challenging” it would be to calculate payments to providers on the basis of patient satisfaction, considering the large differences in the demographics, socio-economic profiles and therefore expectations and judgements of patients in different areas of the UK. These differences mean that it’s dangerous to compare patient satisfaction measures crudely between hospitals.

We’d go further than this, and say something that might surprise you. Patient satisfaction will almost certainly be unreliable as an absolute measure of the quality of care that’s provided. Patients can be satisfied with the outcome – for instance, the fact that their life is saved by emergency staff – but dissatisfied with aspects of the process, for instance the way their life was saved or visiting hours afterwards. What crude patient satisfaction measures don’t tell you is what’s most important – the saving of a life, or satisfaction with the peripheral elements of service around that. This doesn’t mean that patients’ dissatisfaction with elements of the process or service is irrelevant – just that it’s probably not nearly as important as their satisfaction with the outcome. Levels of patient satisfaction need to be weighted by the importance of what they’re rating. This will vary from patient to patient and is highly subjective.

In addition, patients are not all well-informed about what great care looks like. Unlike in consumer markets, they are unable to compare directly between providers at the point of delivery (when they are receiving treatment), and their satisfaction scores are highly dependent on their expectations of the service, which may bear little relation to what great care and best practice actually mean today.

Comparing one hospital or NHS trust with another when they have very different patient profiles (whether older/younger, wealthier/poorer, well informed/poorly informed), and when their patients are therefore likely to have quite different sets of expectations and priorities, seems like a dangerous way to allocate critical resources between areas.

So why measure patient satisfaction at all?

Let’s not throw the baby out with the bathwater. Patient satisfaction may not be a good basis for allocating funding but this doesn’t mean that measuring it is a waste of time. Within a hospital, and within a service, it’s a very valuable way of measuring improvement over time, and identifying opportunities to improve service. Comparing today’s results with yesterday’s results within a hospital is a helpful and valid exercise and should be encouraged and supported.

Instead of the announced policy, we would rather see Andy Burnham encouraging the collection of patient satisfaction measures, and encouraging the use of this data to incentivise improvements within a trust, a hospital or a service through creating a link between improvement in patient satisfaction and staff bonuses, at the margins where it makes a difference to staff but not a critical difference to overall hospital resources.

The report is designed to provide a monthly overview and will convey essential information for your practice management meetings.
The top of the screen displays a colour coded performance chart for the current month, broken down by category. Problem areas clearly show in red, while areas where you are performing well show in green. Click through from the area title to explore and export the underlying data.

To help identify trends, we have included an at-a-glance monthly overview for the past 12 months.

Below the summary chart you will find recent comments grouped into Negative, Neutral and Positive categories. These comments should help provide context to the headline numbers and clearly show the most important aspects of the clinic operation as seen by the patients. The full question data, including comments, can be viewed and exported from the Individual Surveys screen.

Simplified pricing

Effective immediately, we’ve introduced a simplified pricing structure. We now offer our complete service to GP and dental practices for a flat rate of £299 for 6 months, and £399 for 12 months (plus a £120 setup fee payable is your practice hasn’t used PatientPulse before). The packages include unlimited web and mobile web (Phone, Blackberry, Android, Windows Mobile) surveys, plus up to 100 text message surveys per month.

Polyclinic and hospital pricing remains bespoke. Please contact us to discuss your requirements.

New dashboard reports

We’re set to roll out an improved dashboard in January. The new overview screen will show an at-a-glance overview of how you are performing and provide the ideal report for your monthly practice management meetings.

New product for cosmetic / elective procedures

Early 2010 will also see the launch of a new PatientPulse product designed to track the satisfaction of patients undergoing cosmetic or elective procedures such as laser eye surgery, cosmetic surgery and hair replacement therapy.

The core of the service is a survey conducted just prior to discharge after the treatment, and then an automated follow-up some months later. The double survey approach captures immediate patient data at the point of experience, and then results driven data and reflective commentary when the surgery has had full effect.
We are currently trailing the service, and will publish further details in late January / early February.

2010 is going to be a busy year. Until then, the PatientPulse team would all like to wish you a very merry Christmas.

As we begin to look back on the year nearly finished, what developments stand out as important in the patient satisfaction and feedback field? Here are our top five.

1. The GP Patient Survey gets teeth

April 2009 saw the GP Patient Survey, run by the Department of Health, go compulsory, and begin to take place quarterly rather than annually. The results of the survey are now explicitly linked to practice funding (for those practices opting into the Quality and Outcomes Framework), with good ratings potentially being worth £8000 in hard cash to practices. All of which “ups the ante” on the need to get great patient satisfaction ratings.

2. The DoH drops heavy hints about the importance of instant feedback

In May, the DoH published its guide ‘Understanding what matters; A guide to using patient feedback to transform services’, setting out best practice in collecting and understanding patient satisfaction data and using it to make improvements. It stressed the importance of collecting ‘real time’ measures rather than relying on snapshots such as the GP Patient Survey. A strong indication that collecting instant feedback from customers is the way the sector is heading.

3. Practice boundaries look set to be abolished

In September, Health Secretary Andy Burnham announced that Labour would abolish GP practices’ catchment areas, to give patients the right to choose between practices. Despite some scepticism from the BMA and downright opposition from some GPs at the RCGP conference in November, the move seems to have momentum and is also strongly supported by the Conservatives, who have described the boundaries as “a solid wall of defence against real choice”.

The removal of practice boundaries will lead to increased competition between practices for patients – something practices haven’t had to face on this level before. Yet another development that adds to the list of reasons for practices to invest in understanding patient satisfaction in order to improve it.

4. Patient Participation Groups go mainstream

2009 saw a campaign called ‘Growing Patient Participation’ set up by a number of bodies (the RCGP, the BMA, the NHS Alliance, and NAPP, the National Association for Patient Participation). The campaign was all about encouraging GP practices to set up Patient Participation Groups (PPGs), partly in order to represent patients’ views and feed these views into the practice management. Such strong official support should encourage more practices to take action to get closer to their patients’ views.

5. NHS Choices starts publishing the public’s views on GP practices

In November, the popular NHS Choices website started to allow patient ratings and comments to be published on their website for individual GP practices. The service got over 3,500 comments in its first 14 days, with negative feedback unsurprisingly common on the site. Protecting their online reputation is now a powerful reason for GP practices to capture patient satisfaction information themselves, in ‘real time’, before it gets published online.

The worst extreme – legal action

In extreme cases, angry patients may launch legal action. This may or may not be motivated by the possibility of financial compensation. Competition between lawyers fighting to represent angry patients in legal action is intense, and many lawyers take on this work on a “no win no fee” basis.

The NHS Complaints Procedure

More commonly, angry patients will follow the official NHS Complaints procedure. Many official sources of support will lead angry patients down this route – from the Department of Health website, to the Patients Association, which operates a helpline for patients to talk about their experiences (and advises the official procedure if suitable) to PALS (the Patient Advice and Liaison Service) which exist in every NHS trust and PCT. PALS are not themselves part of the complaints procedure, but, like the Patients Association, they help resolve problems informally or can tell angry patients more about the complaints procedure.

Whichever of these routes angry patients come through, most roads lead to the offical process. The formal NHS complaints procedure was re-vamped in February 2009 and has two stages. Firstly patients are advised to contact either the local Practice Manager or a senior member of staff in their hospital department. Complaints may be made in writing or verbally (in which case they will be recorded in writing), and patients are then updated as to the progress of their complaint. If a complaint remains unresolved at a local level, the second stage is a referral to the Health Ombudsman.

Additionally, official complaints can be made to a medical staff member’s professional body, eg the General Medical Council, the General Dental Council, or the Nursing and Midwifery Council. However before taking on the complaint, these bodies are likely to await the conclusion of an NHS complaint.

Unofficial Routes

For patients unwilling to go through a formal procedure, or whose gripe or niggle is not quite serious enough for an official complaint, the NHS Choices website is one officially sanctioned place where they can let off steam about a poor experience. Since November, NHS Choices has allowed the general public to comment on and rate their GP practice or hospital, and has bravely been publishing these comments (following moderation) online. Patients’ contributions needs to be “constructive, relevant and civil” and must not “name and shame” particular medical professionals.

But this isn’t the only way. NHS Choices’ new feedback service follows in the footsteps of a service which already existed – Patient Opinion. Patient Opinion is an independent website founded by a GP from Sheffield, and funded by subscriptions from PCTs, regulators and patient groups. It accepts stories from patients about care received, and publishes these on its website, after moderation of the stories to ensure that they are not defamatory. Anything strongly critical is checked with the author to verify before publishing, and where a story is making a serious allegation against a named professional, Patient Opinion will not publish, but will encourage the author to pursue the complaint instead through formal channels.

There are other websites where you can make critical (or indeed positive) comments about healthcare provision, and some of these (irresponsibly in our view) allow comments to be posted about individual doctors – something Patient Opinion refuses to allow. For example, a US-based website called RateMDs (which also has, at the time of writing 232 doctors listed in England on the site) contains such anonymous claims as “This [named] doctor abuses vulnerable patients”. It’s hardly surprising that the founders of this site report that they get death threats from doctors angry that such comments are allowed to stand without being verified!

Relatively few surgeries actually invite angry patients to have their say on their treatment on the practice premises, or from the comfort of their own homes in an informal but immediate way that’s also non-confrontational. We find this surprising. We would have thought that GP practices that are really interested in improvement would want to encourage patients to tell them first about anything that’s wrong – whether large or small. But in reality, it’s not surprising that they don’t want to encourage niggles to be brought to the fore, because they would have to record these as official complaints, or it would risk increasing the number which get escalated to official complaints. We believe there should be an acceptable middle ground where patients feel free to register their small complaints without fear of getting pulled into (or pulling their practice into) a long formal process.

UK GPs seem happy about waiting lists and the rate of improvement

The Commonwealth Fund survey (full details here) compared 11 countries’ primary healthcare, by surveying a large sample of each country’s primary care practitioners.

Health secretary Andy Burnham will no doubt be very pleased that only 22% of UK GPs reported that patients “often” suffered long waiting times to see a specialist – a result not matched by any of the other 10 countries in the study. (USA came second with 28% but 6 out of 11 countries scored over 50% including Canada, Germany and France). So our GPs seem happy with waiting list times.

Perhaps even more satisfying for Mr. Burnham, a whopping 51% of UK doctors thought that the overall quality of care had improved over the last 3 years. The UK outperformed every other nation significantly on this measure (most countries lingering within the 15-35% range).

He should also be delighted that 81% of UK doctors are satisfied (or very satisfied) in their job, a score only beaten by New Zealand, Norway and the Netherlands.

Not surprisingly, his reaction to the survey was, “This is fantastic news for the NHS and a worthy recognition of the professionalism of NHS staff”.

Hold on a moment.. who’s asking the patients?

These high scores are all very well. It’s great that our GPs seem happy and report high levels of improvement and fewer problems with waiting lists. But aren’t we at risk of being somewhat self-congratulatory? The survey is completely based on the responses (often to rather subjective questions) of healthcare practitioners – not on the opinions of the patients themselves.

We’d like to see a proper international comparison of patient satisfaction levels. Are UK patients really the happiest in the world with the quality of care they receive? What’s the correlation between patient satisfaction and practitioners’ reports of how things are going?

UK GPs are the most interested in patient satisfaction

Of particular interest to us at PatientPulse was which countries’ healthcare practitioners were taking the most notice of patient satisfaction data. Again the UK came out top, which we think is the most encouraging sign that UK patients stand the best chance of seeing continuing improvement.

96% of UK GPs said that they “routinely receive and review data on patient satisfaction and experience”. That should have come as no surprise at all. After all, the GP Patient Survey is now compulsory and regular.

What was surprising, however, was how low the level of engagement with patient satisfaction was in other countries. In most of our European neighbour countries, less than 25% of practitioners regularly reviewed patient satisfaction information – with France particularly clueless as to what their patients think, at a pitiful 2%.

Another key difference between the UK and other countries was the high percentage of UK GPs aware of financial incentives for high patient satisfaction ratings (49%). Again, no other nation came close to this, with less than 5% of doctors in most other countries reporting any kind of financial incentive to improve satisfaction.

Even though we seem to be ahead of the game, we are being encouraged to go even further with the measurement of patient satisfaction. The aforementioned Mr. Burnham said, in a speech to the King’s Fund back in September, “I want to see patient satisfaction measured service by service … Making this information readily available will empower patients and put commissioners on the spot.” We can’t help but agree with that.

We’re firmly of the belief that the measurement of patient satisfaction is key to improving that satisfaction. Which brings us back to our suggestion of an international survey of patient satisfaction levels. Wouldn’t it be interesting to prove the link between the measurement of satisfaction, and satisfaction itself? Testing the truth of the old adage – “If you don’t measure it, you can’t improve it” (and, by implication, if you do, you can).

Not long ago we blogged about the launch of the new NHS Choices online ratings site for GP practices (here’s our original blog post).

More complaining than expected

Now it’s two weeks later and the site has seen over 3,500 comments. It comes as no surprise that the majority of patients using the service will have arrived there looking to vent their frustrations. Taking the time to look up your practice online requires a clear goal – and while many will be in search of opening hours and other specific information, a large proportion will be looking for a way to complain. It’s not surprising there appears to be a marked disparity between the ratings that NHS Choices is attracting and those of the GP Patient Survey.

Just as concerns have been raised about the validity of online ratings in other areas – namely food and travel, so there is concern that NHS Choices provides a survey snapshot of the disgruntled.

With just 14 days’ data it’s too early to tell how useful the service will become. However, it’s for patients rather than practices. And as a patient-focused initiative it may even inhibit the efforts of a management team trying to turn a practice around.

So what’s the alternative?

“Real-time” data collection, initiated within the surgery so that it invites all to participate, remains the most immediately useful way of polling the opinions of patients. The practice can ask questions to which it wants, and needs the answers. Further, we believe that patients given the on-the-spot opportunity to take part in such surveys feel less inclined to make complaints in other ways – including posting reviews on NHS Choices! Services like PatientPulse put the practice back in the driving seat, and help divert complaints to the practice management, who are able to react immediately to them without risk to the reputation of the practice.