The Purpose of Patient Feedback

Civitas, 1 June 2009

The Department of Health issued guidance for PCTs and provider organisations last week on how to effectively collect and learn from patient feedback. ‘Understanding What Matters: A guide to using patient feedback to transform services’ aims to advise NHS organisations on how to make changes as a result of information obtained through patient feedback activity.

Giving patients more choice about how, when and where they receive treatment, and ‘voice’ in the development of such services, has been a major focus of the Government’s health strategy since The NHS Plan was published in 2000. Patients are currently supposed to be given a choice of hospitals for elective, or non-emergency, procedures (although implementation has been spotty). Groups called LINks (Local Involvement Networks) are being funded by the government and run by individuals to find out what patients want, monitor local services, and look into specific issues of concern to the community. Patient Reported Outcome Measures (PROMs) must now be routinely collected for certain procedures, and the 2009 GP survey included more patient experience questions than ever before. With so much talk and so many resources invested, it is worth considering: why the recent focus on patient feedback? What is the ideal outcome of patient-centred care?

People’s expectations of public service accountability have certainly increased throughout the past decade, and recent policies may partly be a political response to that demand. The economic argument is also put forth that with patients given free choice of provider, and providers paid by type and episode of care, providers should be motivated to compete to attract patients and therefore increase their quality of care offered. The other side of that argument asks – do patients really know what they want? Can they (or their loved ones) truly be rational consumers when ill, in pain, or frightened? Do we not spend so many resources on training doctors so that we can trust them, as educated agents, to make these decisions for us?

This raises the question of where to draw ethical and financial lines with patient choice. If a patient walks into his GP appointment and demands a referral for an MRI scan because of a perceived lump on his back, should he be entitled to one? If not, what about the choice of women in labour to request an epidural for pain relief (or even a planned caesarean section)? Is that very different? Physicians, especially in a health system such as the NHS, have an inherent duty to ration system resources. But when does patient intuition trump that of the physician? (And is this the goal of recent initiatives?)

Julian Le Grand in The Other Invisible Hand (2007) refers to studies that suggest all patients really want is “a good, local service.” Is that what we are trying to confirm through PROMs, GP surveys, LINks and the rest? Or do we really, truly, want to offer something more? If the NHS does want to offer more, how much more is it willing (and able) to offer?

Perhaps recent policies are not really focused on choice for the sake of patient choice. Not to say that abundant choice is not a worthy goal; it certainly is if resources allow for it. However, the extent of choices patients can make within a tightly financed health system with relatively defined care pathways simply seems limited, given such a strong policy aim. Could it be that these policies are being used instead as a mechanism to divert staff attention from other things (such as targets)? Maybe the intention is to bring organisational focus back onto providing the best quality care possible within system constraints. What do you think?