The friends and family test: will hospitals raise their game?

From April 2013, every NHS hospital will be required to ask patients in A&E and on the wards whether they would want a friend or relative to be treated there in their hour of need. The Prime Minister says the results will be made public so ’everyone will have a really clear idea of where to get the best care’ which will ’drive other hospitals to raise their game’.

If you follow the logic that ‘what gets measured gets managed’, it makes complete sense to say that a measure that captures what patients think of services will encourage managers to focus more on what matters to patients. And it makes sense to opt for a simple measure that can be easily applied in practice.

On this basis it is hard not to see the appeal of the ‘friends and family test’, which is an NHS version of the Net Promoter Score (NPS) – a customer loyalty metric that businesses including Apple, Philips and American Express use to test customer views. The way it works is simple: ask your customers if they would recommend your service to their family and friends; add up all those who would recommend, subtract those who wouldn’t and you have your score – usually presented out of 10 or as a percentage.

The NPS is not, and is not meant to be, a sophisticated measure of quality. Proponents claim that it is a good predictor of company growth and is highly sensitive to fluctuations and trends in customer satisfaction. If the scores move in the wrong direction, it prompts managers to dig around and find out what needs to be fixed.

However, in health care the NPS is controversial. Some people say that it will not work because most patients do not actually choose where they are treated. Others say that it will not work because support for the NHS is generally so high that it will not have the sensitivity it has in commerce. Some clinicians have expressed concern about what a patient might say after undergoing a necessary procedure or treatment that is distressing or uncomfortable. Others raise technical objections, pointing out that if patients interpret the question differently, it will make the measure unreliable. If a patient in A&E says yes for example, are they recommending the A&E department, or the hospital? Anecdotal feedback from one hospital already using the family and friends test has shown that some patients in A&E reject the question altogether, saying ’I would not wish what happened to me on anyone, let alone my relatives and friends.’

Patient experience measures will only work if clinicians as well as managers take them seriously, and in general they don’t. Clinicians will reject measures they see as inappropriate or unreliable, and will not act on the results.

In a report for the Department of Health last year, Glenn Robert and myself set out the principles that we believe should guide national approaches to measuring patient experience. We believe that any new measure of patient experience should be designed to fulfil the three purposes of the Outcomes Framework. It should give patients and the public useful information; help them hold providers to account and be useful for quality improvement.

We therefore welcome the government’s commitment to developing the methodology for the new family and friends test with local hospitals and GPs. It is absolutely essential that the new measure is trialled in health environments – to find out if the critics were right. And if and when the methodology has been thoroughly tested, and before the measure is implemented, we hope to see a great deal of effort put into communicating the results.