Inpatient survey shows only modest improvements in patient experience

The inpatient survey in England shows that over the past nine years trusts have seen only a modest improvement in quality of care as judged by patients, says a new report from The King’s Fund and Picker Institute Europe.

The first longitudinal study of patient experience by trust, Patients’ experience of using hospital services, finds that while overall there have been small improvements in patient experience reported between 2005 and 2013, the results show a tendency towards inertia or regression to the average. However, when this is set against tightening funding since 2010, the fact that patient experience hasn’t deteriorated is reassuring.

The report, co-written by The King’s Fund and Picker Institute Europe, analysed the inpatient survey data for nine years across 156 trusts – accounting for more than half a million inpatients – and found that generally there was a mixed pattern of performance. For most trusts there was positive improvement in some areas and deterioration in others. 

  • Where there has been a national policy focus, improvements in patient experience can be seen at almost all trusts – for example, in ward cleanliness.
  • Where there have been system-wide pressures beyond the hospital, a deterioration in patient experience is often seen – for example, in lengths of wait for a bed after admission to hospital and timely discharge.

The report also shows there is a ‘ceiling effect’ whereby smaller improvements are shown by well-performing trusts compared to those which started off from a lower baseline. This can partly be explained by relatively high scores to begin with. It is, however, demotivating for trusts which started off well to hear year on year that they are about the same as last year. More needs to be done to find a far more sensitive measure to help trusts. 

The national picture can mask some very different patterns at trust level and our analysis shows there is considerable potential to reduce variation between trusts on some questions, as well as raising overall levels of performance. There are also significant differences between trusts in how they approach and use the data. Our qualitative research highlights some trusts using the data to good effect. One trust told us how having identified noise at night as a key issue for patients they had introduced night masks and ear plugs for patients and installed soft-close bins and doors on wards. This was subsequently reflected in their inpatient scores.

Trusts need to overcome the challenges that are preventing them from using the data in systematic and sustained ways to improve services – these are around leadership, culture, staff engagement, resource and system pressures and trust-wide co-ordination. There also needs to be greater understanding within trusts of how to use the data effectively and the limitations it can present. Changes year-on-year can often be due to random variation and it is much more informative to look at longer-term trends, as this report does, to see significant change. The data should also be supplemented with local knowledge as this will bring further context to the results. A good example of this is at Maidstone and Tunbridge Wells NHS Trust which in 2006 was in the lowest 20 per cent of trusts for ward cleanliness in the inpatient survey and in 2007 was investigated for a superbug outbreak. Its cleanliness score then rose sharply for subsequent years.

Policy-makers, regulators and commissioners should be aware of these data-related issues in order to use the data to offer valuable insights and set realistic expectations about performance improvements.

The report concluded that the inpatient survey data is underutilised at both the national and local level and needs to be used more effectively if it is going to drive better quality in inpatient care. The report’s analysis will help trusts to identify what they are doing well and where they need to direct their attention to deliver improvement.

Veena Raleigh, Senior Fellow at The King’s Fund and the report’s author said:
‘At a time when the NHS is under increasing financial pressure it is good news to see that inpatient care has continued to improve in hospitals across the country. However, this improvement has been modest and it’s time for this valuable survey to be used more effectively. Many trusts are already demonstrating how they can use the survey to enhance care and we hope this analysis will enable more trusts to access the data to make patients’ experience in hospital as positive as possible.’

She added:
‘Policy-makers, commissioners and regulators must also recognise that sustained improvement in the experience of hospital inpatients is unlikely unless the pressures in the wider health and care system ease.’

Chris Graham, Director of Research and Policy at Picker Institute Europe and the report’s author added:
‘Our discussions with five trusts showed the challenges many of them faced in using the survey more effectively. In many cases challenges are longstanding and this is reflected in results that show limited improvement for over a decade. It is now time for all trusts to adopt an organisational-wide approach to the survey, seeking engagement from board to ward so that patient experience data can be an important tool in helping to drive quality care for patients.’

Notes to editors: 

  1. Of the 20 questions we analysed, there were increases in 14 questions and decreases in six.
  2. The full aggregated dataset showing trends from 2005 to 2013 (the first time that longitudinal trust-level data is available) can be accessed in Excel format as supplementary data to the report. 
  3. Patients’ experience of using hospital services: An analysis of trends in inpatient surveys in NHS acute trusts in England, 2005–2013 is available at: www.kingsfund.org.uk/publications/patients-experience-using-hospital-services
  4. For this study, we analysed data from the 2005–13 inpatient surveys for all acute trusts in England to examine trends in inpatient-reported experience at trust level over nine years. We examined 20 questions that contributed to the ‘overall patient experience score’ reported by the Department of Health each year.
  5. The Care Quality Commission has since published the results of the 2014 inpatient survey and the findings are similar to those of 2013 so do not alter the conclusions of this report.
  6. The King's Fund is an independent charity working to improve health and health care in England. We help to shape policy and practice through research and analysis; develop individuals, teams and organisations; promote understanding of the health and social care system; and bring people together to learn, share knowledge and debate. Our vision is that the best possible care is available to all. 
  7. Picker Institute Europe are a leading charity, dedicated to health care improvement and more specifically, to understanding and using people’s experiences effectively, as a tool to support care quality and patient experience improvement.
  8. For further information about The Picker Institute contact Lanisha Butterfield, Senior Communications Manager on 01865 208166 or Lanisha.butterfield@pickereurope.ac.uk