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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.

The second batch of results from the controversial new patient ratings system was published last week by NHS England and NHS Choices.

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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Readers' comments (9)

  • Oh for crying out loud, if you were a patient and you were booked for an operation at a trust and you saw the red exclamation mark on the website, what would you think?

    You would just see the result, you wouldn't know why the warning appeared next to the trust's name and you would want to go somewhere else for your operation.

    After all a red exclamation mark means there must be something going seriously wrong at the trust, you wouldn't know how many people had complained and for what reason.

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  • It's the most hare-brained scheme I have ever heard of. Who the hell thought this one up? It's a good thing in the private sector where there is competition, but let's be realistic, for most people there is no competition, it's NHS or nothing, and your local hospital or nothing.

    I work in mental health services, so who in their right mind is going to say they would recommend our service when they have just been kept in hospital on a section against their will, and forcibly treated - even if it was in their best interest? It's a load on nonsense, and a pity the bean counters haven't got anything more constructive to do with their time.

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  • Well well well, no surprise here then most of us said this, rushed in , we have been threatened with performance management and have to do the famous action plan if we don't get enough numbers, this is health care not bloody Apple!
    We do want to deliver good services let us get on and do it. Biggest waste of money, just what are the CCG's going to do with the scores?
    Another load of lip service....... Good care, compassionate care, timely care in Clean, safe, environment delivered by well trained staff of all grades is what we should and are aiming for not looking at numbers. I challenge all nurses to go away & check out the number of target chasers employed in their directorates/care groups who don't actually influence the delivery of the above for the patient at the coal face so to speak... Oh hang on except to make sure that we have yet another action plan or another email in the inbox and remind us to spend Time at discharge on F&F, that's not a tesco brand by the way!
    Having recently been on the other side as a patient 4 hrs post GA, full of morphine & codeine was asked to do F & F, I did it but I cannot tell you what I ticked!

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  • I'm loving how even with rigging the results, the Coalition still can't massage a survey to show the NHS as failing. Try again Mr Cameron, maybe take a page from the Home Office and drive round some vans with "YOUR LOCAL HOSPITAL SUCKS - GO PRIVATE" written on them.

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  • in the good old hospitals were places run by a matron with teams of nurses, doctors and other allied healthcare professionals supported by cleaners, porters, kitchen staff, engineers, maintenance personnel and others essential for the organisation of that care and smoothing running of the hospital. All took a great pride in their work, worked together and were usually privileged by a good working atmosphere.

    There were sufficient staff to provide high standards of care and a good and efficient service and without an excess of personnel which cost the organisation a fortune beyond its means and patients complained, without just cause, very little.

    The role of the clinical staff was (in brief) to see the patient, examine them, carry out any necessary investigations and provide the necessary therapy and care required and monitor the state of the patient to ensure they were responding to treatment and make any necessary adaptations. they also saw to the comfort of the patient and through good clinical observation ensured they came to no harm.

    Now patient care has become so complex it seems to have become only a part of the work of care teams whose time seems to be much taken up with a variety of other duties. Even more worrying is that there is a huge army of staff who never even come into contact with any patient but take on responsibility for deciding on their care by controlling budgets, resources and work schedules and even bed and some care planning.
    This army, predominantly made up of non-clinical managers and administrators, have an enormous number of different functions and many with such fancy titles and working in mysterious and geographically remote departments, to the rest of the hospital and patient care areas, that nobody really understands what they do and what is going on there.

    Most hospitals now seem more like industrial organisations with strange extraneous departments which must cost a fortune to run (and which would be best spent on the front line care of patients) which seem to have little to do with health care such as PR, press office, Human Remains, OH, Counselling, ombudsman and very many more I don't even know of and probably wouldn't be able to pronounce or spell anyway. One just needs to walk through the hospital corridors or look through the job section of a healthcare management magazine or website to see some more and the mind boggling salaries which accompany them!

    Please bring back proper hospitals where highly trained staff are permitted to do what they have chosen to do, are best at and enjoy doing most* and get rid of all of these ridiculous extraneous clipboard staff with their crazy ideas and then there will be no need for silly forms such as trip advisor, etc. most patents are worrying more about getting well and not indulging in any such daft management games whimsically bestowed upon them!

    'Choose a job you love, and you will never have to work a day in your life.'


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  • michael stone

    You do need some sort of patient/relative feedback, although I don't really like this test at present: I would much prefer a feedback mechanism that provided more detailed comments and more open publication of those comments, even if that loses the 'easily quantifiable' aspect (which seems to be what the current test concentrates on).

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  • I would rather have feedback from the inspectors after all it is their job to do just that. With feed back also constructive solutions, after analysis of the problems encounted.
    Then a futher inspection to check that the solutions have been acted on and taken heed of.

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  • the glass is always half full or half empty depending on how you want to look at it. if your looking for bad you will find it, as bad news sells faster than good.

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  • Why don't you all simply refuse to hand it out? If the government wants them completed, then they should be left in a prominent place at the door of the ward, and the patients can fill them in, if they want to. Surely it's not the nurse's job to conduct surveys???

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