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

This content relates to the following topics:

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.

Comments

Phil Woodvine

Position
Data Analyst,
Organisation
Direct Data Analysis
Comment date
04 September 2013
Your article makes a very good point that The NPS is not, and is not meant to be, a sophisticated measure of quality, and should be used to prompt managers to dig around and find out what needs to be fixed.

In my opinion, the friends and family question ‘would you recommend….’ Should be used alongside additional patient experience feedback to measure areas such as waiting time, safety, information and involvement in decisions, privacy, etc.

By asking the friends and family question in isolation, we are unable to find out why the respondent has arrived at their score and this loses the opportunity to obtain meaningful background data surrounding the score given.

Mark Cannon

Position
Management consultant,
Organisation
Vanguard
Comment date
30 July 2013
The test of a good measure is whether it helps you understand and improve. The F&F test does neither. Ironic that the system used to improve simply evidences the systems inability to so do.

Verite Reily Collins

Position
Medical journalist,
Organisation
aftercancer.info
Comment date
30 July 2013
Agree with comments questioning use of comments; earlier this year I attended meeting at local A & E hospital; we were asked to rate care we had received in hospital. Another woman, on same table, and myself both quetionned what was going to be done to improve certain aspects of care.
Returning to room after end, I found both mine and other person's cards had NOT been picked up; all the rest had.

Surprise - surprise - this hospital has already posted 92@ satisfaction rating!

Peter Palladas

Comment date
14 April 2013
"Some clinicians have expressed concern about what a patient might say after undergoing a necessary procedure or treatment that is distressing or uncomfortable."

- And some people- me - say "I've nearly died three times from this ghastly condition that I may have passed on to my child. As I finally leave this hospital grateful to be alive but desperately worried about the future you're now asking me to speculate what it would be like for my daughter to endure such pain and fear? Can you think of any good reason why I shouldn't hit you?"

Might I suggest an alternative measure:

"Please rate the F&F test: 1. Pointless; 2. Irrelevant; 3. Misleading; 4. Ripe for cheating and gaming; 5. Typical of this inept government; 6. Downright cruel and hurtful. You may choose more than one of the above."

P Smith

Comment date
28 November 2012
Stuart, the idea that this will be available to all patients (or to put it another way: that all patients will have an equal opportunity to take part) is laudable, but unrealistic. Furthermore, although the question wording is standardised (if grammatically incorrect), the data collection methods will vary between Trusts. This will be yet another uncontrolled source of bias in trying to compare results between Trusts. I’m sure we share the view that patient feedback is crucial to ensuring quality in the NHS – I just think the FFT is a very bad way of going about this and is likely to end up setting the cause back.

Stuart Mathieson

Position
Director,
Organisation
CoMetrica
Comment date
23 November 2012
While the DH may have adopted a more traditional NHS survey scale rather than classical NPS 0-10 scale, it is still not decided how the results will be calculated and presented in way the public will understand. While NPS is more sensitive, it needs significantly more explanation to most people which could be a barrier. The standardisation of question nationally and the requirement to make it available to ALL patients rather than a sample are its greatest attributes currently. See more Q&A at http://www.cometrica.co.uk/news/45/20/Friends-Family-Test---Checklist---Are-you-ready.php

O B Fuscate

Position
Watchdog,
Organisation
None
Comment date
09 October 2012
I hope you all haven't missed the fact that the NHS are adopting a 0-5 Scale. The global standard is 0-10 so that means nobody will be able to compare the NHS to any other service operation. 0 to 5 is also very much less sensitive as described in the paper written by the consultants used: http://www.strategicprojectseoe.co.uk/uploads/files/Friends%20and%20Family%20research%20report.pdf

Note also they had only 2 weeks during the holiday period to survey the options!

THEY ARE AFRAID OF THE RESULTS!

P Smith

Comment date
06 September 2012
I would echo Mr Waite's recommendation to read the original paper: maybe you'll be able to work out better than I can how a premise based on customer loyalty in the car rental industry validates this technique for use in the NHS.

Tony Trigwell

Position
PPG Member,
Comment date
04 September 2012
Incidentally; A GREAT BLOG

Regards

Dick Waite

Position
Consultant,
Organisation
RWK Consultancy
Comment date
04 September 2012
Am in Hong Kong just now. Notice NPS is used along with more general/conventional Qs. Think NPS can be useful as a simple add-on to more specific questions of relevance to different clinical settings.

Add your comment