The Friends and Family Test: are you asking the right questions?

It’s crocodiles and swamps!

Last month the Department of Health published the guidance for NHS trusts on the forthcoming NHS Friends and Family Test (FFT). Looking through it is easy to see the many operational challenges that trusts will need to work through to get the FFT up and running. It is also easy to forget the whole point of doing it: to encourage improvements in the services that patients receive from the health system.

Getting up to scratch is going to require a change in working practices. The FFT will require trusts to poll all patients within 48 hours with a net promoter survey-type survey, asking if they would recommend a particular accident and emergency department or ward to their friends and family. There is a huge amount of work to be done: a recent Ipsos survey for the NHS Institute found that only 13% of trusts said they currently offered feedback opportunities for all their patients. Moreover, the expectation that trusts will get a 15% response rate seems ambitious: currently, around a third of all trusts are getting a response rate below 10%.

The implementation challenges are real and immediate. What’s the best method to collect the data?  How should this fit with how trusts currently collect patient data?  How do they make sure they ask every patient, and do this within 48 hours of discharge?  How should the data be reported back, both internally and back to patients?  And all this by next April.

But the challenge to NHS trusts is to keep focusing on draining the swamp, not just fighting off the crocodiles. While racing simply to get the FFT system up and running, it is easy to forget why you are implementing it in the first place. The whole point of the FFT is to put information out there that encourages and facilitates improvements in NHS services. From talking with some trusts recently, the big questions they are focusing on (understandably) revolve around the technical implementation of FFT – while there is less focus on how the FFT feedback can be used to improve services. As FFT beds in, this question of how the feedback can be used to drive improvements will need to come more to the foreground, or an important opportunity – and indeed the point of the test – will have been missed.

It’s clear that improving patient experience is a key priority for the government.  It is embedded in the 2012/13 Operating Framework, and FFT is a lever to deliver this: service improvement runs through the implementation guidance like a strand of DNA.  So expectations are high. 

Underlying this is a concern, from some quarters at least, that progress on patient experience has not been as good as it could be. For instance in her introduction to the Patient Experience Excellence Framework, Angela Coulter asks why progress on patient experience has been so “sluggish”. The interesting question for the FFT is whether it can act as a catalyst for improving services more effectively.

The trick will be not to lose sight of the bigger service improvement wins and there are five questions trust should have in their sights. 

Firstly, have trusts done everything they can to get staff on board with the improvement agenda? Staff ought to be champions and advocates, encouraging patients to provide feedback, and sharing their ideas and good practice on how to improve services. But have trusts got their staff engaged in this so that frontline potential gets expressed?

Does the organisational culture support this? Do staff feel genuinely empowered to make improvements on the ward to produce a better patient experience.  Senior managers may think this is the case, but have they really checked out staff feel this sense of empowerment?

Are staff good experimenters? Real-time feedback can give a lot of detailed information about what a service is doing well or less well. The real impact of this feedback comes when staff feel able to experiment: “let’s trying delivering this service differently – and let’s look at whether our real-time scores go up as a result. And if the scores do not go up, let’s try something different.” While not appropriate for the clinical aspects of care, this approach can give real impetus to improving your patients’ experience of care.

Crucially, is enough being done to bring patients into the improvement process? Patients are the arbiters of whether their experience meets their needs and expectations. Focusing on staff skills and attitudes by itself is not enough – as that would mean any improvements would come from the staff perspective. To really meet patients’ needs, patients have to be given the space to define how services should be improved, or better still, co-design those improvements with staff. So is enough being done to build in approaches like the NHS Institute’s Experience Based Design?

Finally, is the focus on fixing the right things? The FFT guidance says that as well as the friends and family test question itself, trusts should decide locally what follow up questions to ask to help drive service improvements. Getting those follow up questions right is key – and listening to the improvements that patients want will help trusts focus on the improvements that matter to patients.

The challenge in all this is to deliver a consistently good (and improving) experience to patients.  To achieve this, trust need to make sure they have aligned the patients’ voice (their needs and service expectations) with what is going on inside the trust to deliver those services. The NHS already has numerous, innovative examples of listening to patient voices, and with approaches like EBD, it is already working closely with patients to redesign services.

Where trusts could maybe do more is to pay more attention to how all their internal processes, activities and decisions support this.  Good patient experience is not just down to frontline staff, it is the sum total of everything that happens inside the trust to support those frontline staff. Consider a thought experiment: think of a service you use where you get a consistently good customer experience.  The test question is: what happens inside that organisation to ensure that consistently good experience? What do the Board do to set this agenda?  How are staff trained, supported, appraised and recognised? How are internal processes designed to support and quality assure the frontline experience?  Interestingly, when we work with our commercial sector clients, they often pay considerable attention to these questions.  As the NHS starts to ask how to use FFT feedback to improve patient experience, addressing these questions will be an important part of the challenge.