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Implementing the Friends and Family Test

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The Friends and Family Test was introduced to improve the patient experience and patient care. One trust shares its implementation plan and what it learnt as a result


This article discusses the background to the Friends and Family Test, highlighting the commitment to improve the patient experience. It also demonstrates how patient feedback was used to improve services in Aintree University Hospital Foundation Trust.

Citation: McIntyre L et al (2014) Implementing the Friends and Family Test. Nursing Times; 110: 45, 12-14.

Authors: Lyn McIntyre is deputy nurse director - patient experience, NHS England (Midlands and East); Karen Davies is patient experience manager, Carolyn Fox is deputy director of nursing, June Taft is assistant director of nursing; all at Aintree University Hospital Foundation Trust.


An emphasis has been put on improving standards of care across the NHS after examples of poor care at Mid Staffordshire Foundation Trust were brought to light (Francis, 2013). Additional reports by the Care Quality Commission (2011), Keogh review (Keogh, 2013) and the Berwick review (Berwick, 2013) highlighted the importance of listening to patient feedback and being able to demonstrate improvement as a result.

Examples of poor care have also been demonstrated in the rising number of complaints reported across the NHS (Clwyd and Hart, 2013) and with the Patients Association (2013) also reporting a 26% increase in the number of complaints it receives. It is important that the public and patients are informed, listened to and have continuity of care (Clwyd and Hart, 2013). The Keogh review also recognised the desire patients have to be involved in improving services and the added value their voice brings when organisations use their feedback (Keogh, 2013).


In May 2012, the prime minister announced the introduction of the Friends and Family Test to improve patient care and identify the best-performing hospitals in England (Department of Health and NHS Midlands and East, 2012). The commitment given to both patient and employees to embed the FFT into daily organisational life was made in NHS England’s (2014) business plan, Putting People First.

The concept of the FFT is based on net promoter methodology that is used across industry in the UK and in the healthcare sector worldwide (Reichheld, 2003). The test is an overarching indicator of patient experience which, when combined with a follow-up question, can be used to drive cultural change and result in an increased focus on the experiences of patients.

Implementation and national roll-out

The FFT asks “How likely are you to recommend our ward/accident and emergency department/maternity service to friends and family if they needed similar care and treatment?”. Trusts are also expected to ask a follow-up question to obtain patient feedback that can be used to help drive up improvements in services.

The test was initially piloted in an acute inpatient ward in 2012/13 in the Midlands and East region. The implementation of this phase, led by the merged strategic health authorities (East of England, East Midlands and West Midlands), was one of five ambitions to create a customer care revolution (NHS Midlands and East, 2011). Organisations across the Midlands and East region took part in the pilot, which trialled various methodologies and helped to develop NHS national guidance for the FFT.

National implementation of the test was, or is, planned for the following:

  • Acute inpatient and A&E - implemented in April 2013;
  • Maternity - implemented in October 2013;
  • Staff friends and family - implemented in April 2014;
  • Outpatients - December 2014;
  • Primary care - December 2014;
  • Mental health and community services - December 2014;
  • All other NHS-funded services - by the end of March 2015.

The initial focus for the FFT was to ensure a 15% response rate in acute inpatient and A&E departments. This information is collected and reported via the Unify data collection system. The second part of the test asks for feedback that is used by the trust to improve care.

Trusts have initially concentrated on the data collection model such as tokens, where patients are given a token to slot into a box on the scale of “extremely likely to recommend” to “extremely unlikely to recommend”, so have not always had the systems in place to record, theme, report and implement improvements. However, the real strength of the FFT lies in the rich source of patient views that can be used locally to highlight and address concerns much faster than traditional survey methods. Comments are rapidly available to frontline clinical staff so practical action can be taken to address problems that concern patients. Positive comments are also important for maintaining staff morale.

To incentivise implementation progress and improved experience outcomes for both people using care services and staff delivering care services, a commissioning for quality and innovation payment has been put into place. This is annually reviewed to ensure it meets changing needs within a shifting NHS landscape (NHS England, 2013).

Case study

FFT in practice: Aintree University Hospital Foundation Trust

The trust considered several approaches to FFT data collection, ranging from interactive surveys on bedside televisions to a postal service coordinated and processed by an external company. After considering the solutions on offer we decided to pilot an internal paper solution, collated and processed by the patient experience team, for both inpatient wards and the A&E department. Funding was secured for two patient experience assistants, whose role was to collect the cards each day from newly installed patient comment boxes, and to input the FFT score and comments into a specifically designed database within the Aintree Business Intelligence system.

The card was designed to not only ask the main FFT question but also give patients an opportunity to explain the reason for their score. This enabled the trust to obtain important qualitative data, recognising good practice and areas where our patients feel we need to improve.

To ensure patients were confident enough to provide honest feedback, and in line with the FFT guidance, there is no patient identifiable information on the card. Additionally, patients are asked to post their completed card into the confidential comment box when they leave the ward instead of handing it back to staff. Comment boxes have also been installed at the main entrance/exits to the hospital so patients can post their comments in an area outside the care environment if desired.

Engaging staff and volunteers

The trust’s deputy director of nursing led a “Countdown to FFT” communications drive that was launched in March 2013. Meanwhile, the patient experience manager personally delivered a presentation to every ward and department manager, emphasising the importance of the FFT as a mechanism to support improvements in care. The focus was on giving ward staff a better understanding of how their patients feel about the care they receive, while highlighting the importance of the FFT for the trust as a whole. This approach brought the national initiative alive and made it relevant for our frontline staff.

The trust had T-shirts printed that were worn by the patient experience team and volunteers (Fig 1). Banners were hung on car park entrances and posters were displayed around the organisation. The countdown to FFT also featured on all trust screensavers and in the hospital magazine.

From the outset, it was clear central coordination would be needed to help individual areas monitor their:

  • Percentage returns (the number of responses received against the number of patients eligible to respond);
  • Net promoter scores;
  • Understanding of patient feedback.

A daily report was distributed to ward and department managers. The deputy director of nursing provided senior support to keep the FFT on track, promoting the importance of embracing it throughout the organisation from ward to board.

How did we improve our results?

Response rates from the inpatient wards immediately achieved well in excess of the nationally required 15% target. A&E, however, initially achieved a response rate of only 10% using written cards; by mid-April 2013, it was clear that this approach alone would not achieve the required response rate of 15%.

Alternative collection methods were investigated and we decided to undertake a six-month trial of SMS text messaging and interactive voice messaging within A&E; this started in June 2013. An automatic text message was sent to a mobile telephone, or an automated call made to a landline, asking patients the FFT question on the evening after their discharge. Patients who chose to answer were subsequently given the opportunity to provide the reason for their response, ensuring qualitative data was captured. This new approach saw an immediate improvement in the A&E response rate, which has been maintained since implementation (Fig 2).

How did we collate our data and learn from it?

Once the trust consistently achieved a response rate higher than the national target, we turned our attention to understanding and learning from our net promoter scores and qualitative data, focusing on how we would use the FFT to drive improvements in the experiences of our patients and their family members.

Initially, a process was established whereby positive or constructive comments were forwarded to the ward manager within 24 hours of receipt, and changes to practice were shared organisationally via the patient experience team. Now we have a shared database, which is updated weekly and contains action plans populated by ward managers with local improvement initiatives. This new process reduces email traffic, reduces potential errors and duplication, and offers a consistent approach to action plans across all wards. A shared database also allows the patient experience team to identify themes emerging from qualitative feedback (Fig 3).

Each ward displays on its “How Are We Doing?” board FFT response rates, net promoter scores and comments it has received. The board highlights the improvements that have been made so patients and the public can see them. Our “speech bubbles” on this board have also been well received - they are easy to read and give patients and their relatives the chance to see the changes that are directly related to patient feedback. Our results are also available on the trust’s website and on the NHS Choices website, as part of NHS England’s Open and Honest Care project.

Now the FFT is embedded within our inpatient and A&E areas, we have also started to triangulate the comments we receive against complaints and incidents to identify trends.

Implications for practice

The programme has identified that:

  • Strong leadership at board level is essential to ensure engagement and support throughout the whole organisation;
  • There must be clear, concise communication about the purpose of the FFT and the opportunity to drive improvements in patient experience;
  • Staff must be engaged from the beginning of the process to make sure the patient experience is everybody’s business;
  • Feedback mechanisms should be put into place so patients can see what organisations “do” with their feedback and what improvements are made as a result;
  • The results of the FFT, along with the supplementary insight it generates, enable staff at all levels from ward to board to be informed and empowered to understand, celebrate and build on what is working well in their clinical area, while tackling areas of weak practice.


The ongoing roll-out of the FFT across all NHS services will continue until March 2015. Once fully established and embedded, the FFT score will be a recognised measurement for understanding patient experience across all NHS service providers. Giving every patient the opportunity to comment on their experience will ultimately enable service providers to better understand what they are doing well. It also acts as a catalyst to ask why patients have awarded the score they have, providing insight that can guide changes for patients and the care they receive.

Since the introduction of the FFT in April 2013, more than two million responses have been collected from NHS trusts. This is an impressive achievement and provides evidence that an increasing number of patients are being enabled to have their say about their experiences of care across a range of services. Many trusts have already started to realise the benefits of the FFT and can demonstrate that the voices of patients and their families are not only being heard, but are also helping to shape and drive improvements within their local NHS.

Key points

  • The Friends and Family Test was launched in 2013
  • The test is standardised nationally, but trusts can choose how best to implement it within their own organisations
  • The test is an easy way for patients to comment on their experience of health services
  • Relatives can also complete the FFT
  • Since the launch of the FFT, more than two million responses have been received
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