A recent analysis of patients’ comments about the NHS highlights a widespread problem, but comes to the wrong conclusions about how to fix it.
The Patient Opinion website provides a place where NHS patients can comment on the care they have received. Patient Opinion is a not-for-profit company that was originally funded by the Department of Health. It is now independent of the government, although it relies on subscription income from NHS Trusts.
Even so, it seems to be linked in a mysterious way to the official NHS Choices website, and it appears to contain some official responses from the NHS Trusts that subscribe. So its independence from the NHS is not exactly clear.
Its recent report, In their words: What patients think about our NHS, (PDF) is based on a sample drawn from thousands of stories:
This report is a first in that it aims to quantify patient stories and opinions that have so far gone unheard or been dismissed as too anecdotal. It brings together five years’ worth of patients’ views on the treatment and service they have received at the hands of the health services.
I have not recommended Patient Opinion in the past, because in the past the way the site was designed had a strong bias towards showing the NHS in a good light. It did this by asking everyone who took part to make both positive and negative comments. Then it only highlighted the positive.
For example, a couple of days ago a patient complained about constant disagreements among hospital staff:
On one occasion there was a stand-up row in front of the patients, which had to be broken up by another (less senior) nurse. This was particularly unpleasant as they tried to involve me in the situation.
At the end, this patient remarked:
On a positive note, the trainee nurse and volunteers were the best part of my stay – respectful, gentle and kind.
The site used to be designed to place that positive remark on the front page, hiding the complaint. Users found ways to circumvent this bias, by making backhanded ‘positive’ remarks along the lines of, “The best part of my stay in hospital was leaving.” The site seems to have changed recently, and the new site is more respectful of the overall balance of patient’s views.
A further source of bias is that serious complaints are unlikely to appear on the site. As a result, relatively few of the complaints on the site are about quality of care and clinical outcomes. The site gives the false impression that the NHS’s failures are mostly trivial.
In the report, the analysis found that patients’ most common complaint is about staff attitudes, with complaints about care and compassion coming a close second. Oddly, the diagram on page 9 highlights the care and compassion figure, but throughout the rest of the report the major problem with staff attitudes is acknowledged. Complaints about staff attitude where when (page 16):
Patient perceived staff as rude, arrogant, lazy or having a negative attitude.
Unfortunately, I found the neurologists…to be incredibly arrogant, unapproachable and happy to make (incorrect) assumptions.”
The report groups the four top categories of complaint together. Taken together, these four account for nearly half the complaints:
- Staff attitudes
- Care and compassion
- Poor communication
It notes that the top four categories are related (page 10):
These top four concerns all share one quality; [sic] they happen at a one-to-one, staff to patient level…
However, this grouping is partly an artefact of the analysis. Complaints about dignity and inclusivity, for example, were treated as separate from staff attitude. That makes no sense.
And there were three other communication categories. If these related categories had been included, then complaints about the way staff approach their job would have accounted for the majorty of all the complaints.
The thing that links all these categories of complaint, not just the top four, is that they are complaints about the NHS culture.
The way the report groups the categories of complaint is a weakness, but a bigger weakness is the way it makes assumptions about what can be done. The same quote from page 10 continues to say that the top four concerns:
…can all be remedied quickly and cheaply…ultimately, the way a doctor or nurse interacts with a patient is something that [sic] can easily change themselves today.
On the contrary, culture change in organizations is slow and expensive. The vague hope that individuals will try to be nicer in future does not achieve it.
What has to happen is that the organization as a whole, the hospital or the Trust, needs to have a different focus — a focus on providing a high-class service with no slip-ups. The thing that will change that organizational focus is patient choice.
The purpose of patient choice in the NHS is not to satisfy the few patients who quite like the idea of having a choice. Its purpose is to change the staff culture, as staff (including managers) begin to understand that patients can choose to go elsewhere.
Alongside the change in organizational culture, staff need to have something to guide them in improving their behaviour. The principles of patient dignity and inclusivity are some of the guides. They are not important because a few patients like the sound of them. They are important because they are positive ways to guide staff to behave more appropriately.
NHS Trusts respond to some of the complaints on the site, but the responses tend to be unhelpful. Many of them only say that patients should contact PALS, the NHS’s own advice service, which is not independent, not public, and widely considered to be useless.
Even the fuller responses tend to miss the point. For example, the report quotes a complaint about a mental health trust:
My daughter was 17 when we first had concerns over her depression.
…She had made a suicide attempt by this point. Due to her age, this problem has taken a year to resolve. The system needs to be changed. Mature adolescents are different to adults and should be treated accordingly. I really do not want another teenager to go through the experience my daughter has endured over the past 12 months due to the system not being able to cope.
A year to resolve depression is quite good by NHS standards, I would have thought. Depression still unresolved after ten years would not be uncommon.
Anyway, the response from the Trust ignored the complaint that the system had been unable to cope, only saying that 17-year-olds would in future be seen by the part of the Trust that treats children and adolescents, and leaving it unclear what would have happened if she had turned 18 during her treatment.
We have changed our referral criteria for Adult Services…
…I hope it is an important step towards ensuring that people at this often difficult and vulnerable stage in their lives receive age-appropriate mental health services.
The report describes this as an example of “a full and helpful response”.
Despite its weaknesses, Patient Opinion is a useful place to go to find out what people are saying about your local NHS. It can also be a useful place to make a complaint public, if your complaint is not so serious that you want to pursue it formally.
Although it might soon be made obsolete as patient choice gradually forces the NHS Trusts themselves to listen to their patients more carefully, I recommend Patient Opinion to anyone who has something to say about their NHS treatment.