Service improvements or simply closed hospitals?

The NHS needs to save money, Huge amounts of money. This requires fundamentally changing how things are done, not merely making current practices more efficient.

However, whenever PCTs embark on what is claimed to be service-redesign to deliver better, modern care in new ways that also save costs, they are rapidly attacked by their regional media and "angry, local people". For example, NHS Surrey told HSJ:

"...the campaigners were completely focused on “bed closure rather than service improvement” and invitations to come and see how new services were being delivered had so far been shunned."

This is of course not surprising and requires PCTs to re-engage with their public in innovative, open and transparent ways. Again, a whole new way of operating. iWantGreatCare is working with PCTs to address this problem, using real-time patient experience as a "barometer" of opinion, whilst also showing service-users that current structures and services are not only financially unsustainable, but also frequently deliver mediocre patient experience.

Real-time monitoring through iWantGreatCare allows PCTs to demonstrate that patient experience with existing services is far from satisfactory, and then to show that redesign has not led to a worsened patient experience. Only systematic, quantitative systems (implemented before redesign) have the potential to counter the problems that NHS Surrey and others are already facing.

It is hard to tell people their local hospital has to close. It is not quite so hard if you show them that real people - their peers - prefer the new provision and that the solutions deliver happier, healthier patients. That is the level of patient engagement needed not just locally, but also at a national level as we battle to reshape the NHS into a high quality, cost-effective, patient-centric service fit for 2010.

Mid Staffordshire - why was nobody listening to the patients?

There are so many ways in which the disaster at Mid Staffordshire hospital should - and must - lead to improvements in patient care, not just locally but across the entire system of the NHS. Whilst politicians and the Department of Health have been quick to claim that it is just an isolated example, the reality is that it reveals an almost total inability of the national monitoring and safety systems to protect the patients who were admitted to the Mid Staffordshire hospital. The facts are as clear as they are shocking: analysing mortality data for Mid Staffordshire Hospital reveals excess mortality since 2003, yet in the six years since then the Health Care Commission increased the rating for the hospital from Fair to Good and the hospital was given Foundation status - supposedly a marker of excellence in which patients can have complete trust.
To make matters worse, the company monitoring outcomes data only "raised the alarm" in 2007, after they were alerted and asked to look in detail at the mortality information. This would be analogous to an organisation responsible for ensuring airline safety "alerting" the public to problems years after a plane crash that killed 400 people.
So what lessons can be learnt, what changes have to be put in place to ensure that we don't have yet another "one-off" in a few years time, and what role does patient experience have to play in this?

Most importantly, everybody working in healthcare has to listen intently and continuously to the patients. If patient-centric care means anything, and is to be more than just a politically correct buzz-word, it means continuous, detailed and open listening to the voices, experiences and opinion of patients. Patients, their families and carers in Staffordshire had been complaining loudly from 2003 about the shocking state of their hospital and their voices were ignored completely. The Trust itself appears to have dismissed them, and the Healthcare Commission has no system to track and monitor the level of complaints made about a hospital - until the patients themselves complains to the HCC. There is extensive evidence that the perceptions of patients and their experience is an accurate marker of quality standards in hospitals - yet the NHS does not harness what is probably the most accurate, early system of detecting poor quality healthcare: the voices of those using the service. One can only speculate how many lives would have been saved if the NHS systematically incorporated real-time collection and monitoring of patient experience as part of safety and monitoring systems.

"Insanity: doing the same thing over and over again and expecting different results." Albert Einstein
Rather than listen in real-time to the public, the HCC requires patients to be dead before their "experience" activates the systems and alerts. One doesn't need medical training to realise that this might be somewhat too late! However, not only is this a patently ridiculous way to protect patients (akin to a smoke-detector that only goes off months after the house has burnt to the ground), but it also lacks the sensitivity necessary to improve quality across the NHS. As anyone who has worked in a hospital will tell you, things can be very bad indeed before mortality rates increase.

Continuous, real-time, granular monitoring of patient experience has the unique ability to solve some of these problems and greatly increase the sensitivity, accuracy and timeliness of systems put in place to monitor quality and safety of the NHS. We need to make it easy for patients and their carers to not only record their experience, but to ensure this invaluable information is analysed in real-time and provided to Trusts (and the regulators and monitors) in a fully open, transparent way. At the simplest level, all Trusts (primary, acute and mental health) should be required to display the number of complaints they have received, standardised to the number of patients they see, on the front page of their website. Even such a simple thing would help inform the choice that patients now "enjoy", whilst perhaps concentrating the mind of the management. (Perhaps Monitor might even be tempted to look at that number when coming to their decisions?)

The experience of patients has to be a metric and tool that the board and management of Trusts use in the same way that they use data about infection rates: a critical, sensitive and core metric of quality. Perhaps then we might actually get closer to a truly patient-centric NHS.

• Where are the NHS watchdogs now? (guardian.co.uk)


• Heads should roll over the Staffordshire hospital scandal (telegraph.co.uk)


• 5 more fresh articles...

Poor communication predicts complaints against doctors

But more importantly, predicts unhappy patients not getting the care they need.

An excellent patient experience (as measured by quality of communication from their physician) not only predicts quality clinical outcomes, but is important in protecting the doctor (and her organisation) from complaints and reduces the risk of litigation.

Of course all good doctors already know this and make monitoring and continually improving their communication skills a priority. It is interesting to see "early-adopters" amongst doctors now embracing web-based feedback from their patients as another tool to ensure excellence.

This JAMA paper from 2007 (JAMA. 2007;298(9):993-1001) describes a detailed, ten-year prospective study of complaints against doctors, and then performs regression analysis against their exam results in clinical communication skills. Final line of the conclusion is clear and powerful support to all who understand that an excellent patient experience is an integral part of excellent care, and not just a "nice to have":
"...the patient-physician communication score in the clinical skills examination remained significantly predictive of retained complaints (likelihood ratio test, P < .001), with scores in the bottom quartile explaining an additional 9.2% (95% CI, 4.7%-13.1%) of complaints."

Whilst communication skills are now an integral part of most medical schools' curricula, patient satisfaction scores are not increasing - is it time to make communication skills a core part of regular, re-training for all doctors?