Will payments linked to patient experience improve quality?

Andy Burnham MP, Secretary of State for Health, announced recently at The King's Fund that hospital payments will be linked to patient experience at service level. This policy could be introduced as early as next year, when revised hospital tariffs are announced.

While the NHS Next Stage Review and Mr Burnham's announcement give renewed priority to patient experience, measuring this aspect of quality is not new. A large, national programme of patient experience surveys that covers all trusts in England has been running since 2002, and the results have been used in the performance assessments of NHS trusts by the national regulator (first the Healthcare Commission, now the Care Quality Commission). Such data, together with qualitative and other feedback collected locally, is essential to improving services.

However, linking patient experience at the level of individual services to hospital payments at a national level is ambitious and has a number of implications.

Implementing high-quality, robust surveys with adequate statistical power to produce discriminating and useful results is a specialised, lengthy and costly business. At trust level, current surveys sample about 800 inpatients per trust, with a response rate of about 60 per cent (and falling). To produce reliable data to compare hospitals at service level would require new surveys with much larger sample sizes. This will significantly increase costs of both development (currently met centrally) and implementation (met by trusts).

If this data is to be used as a basis for payments to hospitals, comparative data would be needed across all providers – including independent health care providers delivering NHS-funded care. While many providers and clinicians would doubtless welcome the prospect of such rich data to inform their own improvement programmes, they may not be willing to incur the additional costs to measure just one dimension of quality. Whether this is the most cost-effective use of resources in the looming stringent economic climate will need testing. Furthermore, patient numbers at service level may not even be adequate for such surveys to be technically feasible.

Linking payment for hospitals to patient experience assumes that patient feedback is an unequivocal and unambiguous marker of the quality of services. Patient-reported experience is undoubtedly central to high-quality care, and vital for identifying areas for improvement in quality – the central aim of the national survey programme. However, such information needs to be interpreted and used with care. Allowances may need to be made for external factors that can influence the results but may be unrelated to quality. For example, the results may be related to variable response rates among different groups and areas, and research shows that patient-reported experience is associated with a number of patient-related characteristics, such as age, gender, social class, self-reported health status, and where they live (see the CQC website).

It is unclear how this policy will impact on individual and organisational behaviours, or how it will interact with other incentives and measures such as quality accounts. While centrally driven targets have undoubtedly driven changes in process and structure that have, for example, improved access and reduced waiting times, improving patient experience requires a great deal more in terms of changes in behaviours and attitudes of frontline staff. It's uncertain whether offering financial incentives to organisations can engender this. Given the associations between patient experience and staff satisfaction, Mr Burnham's commitment to measuring staff satisfaction may well prove a more cost-effective way of ensuring higher standards of care for patients.

Strengthening the focus on patient care is vital if the vision in High Quality Care for All is to be realised. While the general principle of rewarding hospitals for delivering high standards of patient care is to be welcomed, linking payments to patient experience in every service area across the NHS should be assessed for impact and cost effectiveness before being introduced.

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