Published: 09 March 2020
James Munro, Chief Executive of Care Opinion, argues that there is extraordinary, yet untapped value in patient feedback which is not being recognised in current policy and practice. His blog follows the launch of the NIHR’s themed review on using patient feedback to improve care.
Gathering feedback from people who use health services sounds like a simple and straightforward matter. Doesn’t everyone love feedback?
But it turns out – as the recent NIHR themed review 'Improving Care by Using Patient Feedback' makes clear – that this is a topic beset by complexity, uncertainty and disagreement. It’s also an area which can provoke strong emotions both from those offering feedback, such as: “why isn’t anyone listening?” and those receiving it: “why am I being attacked when I work so hard?”.
What is feedback for?
Much of the difficulty turns on the question of purpose: what is patient feedback actually for? From a health system perspective, feedback tends to be seen as a measure of performance or problems. The NHS Friends and Family Test (FFT) started life this way: it would “shine a light on standards of care throughout the system and help expose the shocking examples of poor care that have been coming to light”, said then Health Secretary Jeremy Hunt in 2013.
For patients and staff, by contrast, the value of feedback is often in its ability to prompt change, whether practical: “we’ve improved our appointments system”, or perceptual: “I hadn’t realised how this feels for you”. And sometimes, feedback is simply transactional: people reporting the issues which impede their access to care, to get them resolved in the here and now.
Of course, the intended purpose then shapes the kind of feedback collected, and that in turn shapes how feedback work feels to both patients and staff. In ongoing work, Lauren Ramsey at Leeds University is exploring feedback cultures. In many healthcare organisations the measurement paradigm is dominant: feedback is ‘data’, so feedback work is collation, analysis and reporting. The role of patients is simply to feed the machine with more data (FFT, I’m looking at you), in the hope that it has some effect.
In some organisations, feedback is seen in consumerist terms: is it a concern or a compliment? Feedback work here is casework: let’s resolve customer concerns as fast as we can.
And in some organisations (perhaps the minority), feedback is seen as a stimulus to learning, improvement and even widespread cultural change. In these, feedback work is focused on listening, sharing stories, seeking improvement opportunities, fostering patient-centred thinking.
These diverse organisational feedback cultures feel very different to clinical staff: in measurement cultures, feedback looks like a management tool. In consumer cultures feedback is a problem or a pat on the back. In improvement cultures, feedback can become a rich source of learning, encouragement and even solidarity with patients.
Accentuate the positive
Much discussion of patient feedback seems to conflate feedback with complaint, but this is to ignore the extraordinary waves of gratitude which flow through all feedback channels. And sadly, our feedback systems often do ignore this positivity. What an extraordinary missed opportunity for learning and change this is. Positive feedback lifts morale, boosts confidence and instills pride. Could patient feedback support the Institute for Health Improvement’s notion of “joy at work”?
Recent evidence suggests that gratitude expressed by families towards clinical teams may result in improved team performance (the opposite of the ‘incivility effect’), thereby creating benefits for other patients. Publicly expressed gratitude may also have positive effects on those who witness it. And yet, as Giskin Day has pointed out, healthcare organisations have formal systems for negative feedback but no place at all for the positive. The implicit assumption that we can only learn from mistakes is itself mistaken.
Evidence cited in the themed review makes clear that clinicians are profoundly ambivalent about patient feedback, seeing it as essential, yet of uncertain validity. When it comes to online narrative feedback, clinicians tend to become wary or even hostile. Yet the evidence on both formal complaints and online feedback shows that the large majority of patients are seeking explanation and improvement, not advantage or retribution.
Feedback is a relationship
And this brings us back to why people offer feedback in the first place. Why make the effort, especially if you risk being ignored, patronised or pathologized? The Inquire UK study, cited in the review, highlights the notion of “caring for care”: many of those giving feedback felt they could do no other. Their efforts were intended to help, to encourage, to improve, to support the NHS and those within it. As active citizens, they felt it their duty to act as ‘critical friends’ to a highly valued yet imperfect public service.
If our understanding of, and our systems for, patient feedback are limited to seeing it simply as data, concerns, compliments, or even stories, then I think we are missing this bigger picture. Feedback is a relationship. It is one way that people receiving a service can express their care, in return, for those who provide it, and for others who will use it. It is an expression of the values of equality and mutuality which lie at the heart of our health service.
Our current approaches to patient feedback recognise little of this – and it is time they did.
James Munro, Chief Executive, Care Opinion