Nurses raise concern friends and family test is alarming patients
The “misleading” presentation of results from the government’s flagship patient feedback test is alarming the public and damaging staff morale, senior nurses have warned.
Nursing directors say their trusts have been branded among the worst in the country by the new “friends and family” test, despite only a handful of patients saying they would not recommend their services.
Since April all hospitals providing NHS-funded acute care in England have been required to ask inpatients and those in accident and emergency whether they would recommend the service and the care they received to friends and family.
The test is based on a system called a net promoter score, which is widely used in the private sector to measure customer satisfaction. Possible scores range from -100 to 100 and anything positive is regarded as a good score.
The results of the friends and family test in July showed the NHS in England had an overall score of 70 – around the same as technology firm Apple, which achieved a score of 69 in 2012 and is said to have the best net promoter results in the private sector.
Just two acute care providers – Barnet and Chase Farm Hospitals Trust and Medway Foundation Trust – scored below zero, but only for A&E services.
However, despite this apparent success, question marks have been raised over how the results have been presented by NHS Choices. Its website identified a fifth of trusts with the least good ratings with a red, warning-style symbol and the words “among the worst” – even though they had achieved positive scores.
Yeovil Foundation Trust was one of the 20% whose performance against the test in June was badged in this way on the NHS Choices website. A local newspaper subsequently ran a story declaring the trust was “among the worst NHS trusts in the country”.
This is despite only six inpatients out of 362 at Yeovil saying they would be unlikely to recommend it.
Helen Ryan, the trust’s director of nursing, accused NHS Choices of being misleading in the way it had chosen to present the results, and raised concerns at the use of the red symbol on the website.
“In their effort to give people a choice, they’re giving people misleading information which could worry patients unnecessarily,” she said. “I continue to be baffled that the NHS can’t take the opportunity of saying well done to itself for doing a good job.”
Nursing directors from other trusts in a similar situation told Nursing Times they shared Ms Ryan’s concerns. Angela Monaghan, chief nurse at Harrogate and District Foundation Trust, said the way NHS Choices had presented the data was disappointing.
Homerton University Hospital Trust chief nurse Sheila Adam described the test as an “excellent concept”, but said she was concerned at the way it was being used to rank organisations and was not comparing like with like.
She said: “Patients don’t understand the net promoter score. What they do understand is a big red [exclamation mark] on NHS Choices, which is quite frightening but isn’t truly reflective of the quality of care.”
Ms Adam highlighted that the test took no account of variations in patient response rates or the type of services an organisation provides.
For example, the five organisations with the best scores for inpatient services are all specialist hospitals. Top was the Royal National Hospital for Rheumatic Diseases Foundation Trust, where all 23 patients surveyed said they would be extremely likely to recommend the service.
In addition, concerns have been raised about the way the net promoter system weights the responses from patients and that it is unfairly tipped towards the negative.
Patients who say they would be “likely” to recommend a service, rather than “extremely likely”, are classified by the test as neutral and do not count as promoters – only patients who say they are “extremely likely” to recommend a service are viewed as promoters. However, those who say they are either “unlikely” or “very unlikely” are both counted as detractors.
When the first set of national friends and family test scores were published in June, 36 wards had a negative score and were widely reported by the national media as having “failed”. But only three of these wards were among the 30 that received a negative score in July.
In both months, the vast majority of the wards with negative scores had very low numbers of response rates – calling into question the robustness of the scores they are based on.
Respected health survey experts from the Picker Institute said scores for wards where less than 10 patients filled in the friends and family survey should not be published.
Chris Graham, the institute’s director of policy and research, said: “We strongly recommend that data based on very small numbers… should be suppressed when reporting to avoid creating unreliable impressions, unnecessarily damaging staff morale, and alarming local communities.”
Mark Platt, Royal College of Nursing policy advisor on patient and public involvement, said the way NHS Choices presented the information was “likely to be confusing” for patients.
“In terms of supporting patients to make an informed choice I’m not sure the NHS Choices approach is very helpful,” he told Nursing Times.
NHS England has said it plans to review the operation of the friends and family test once six months of national data has been collected. A spokeswoman said they would seek views from trusts and patients on how best to present the data.
In a joint statement NHS England and NHS Choices said testing of the exclamation mark system indicated users of NHS Choices “interpreted the red exclamation mark as a ‘warning’” and not “an alarm that an organisation is somehow dangerous”.
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