The effective commissioning of a health and social care service is a significant challenge. Decisions around service availability, quality and utility are often complex and multi-layered. But it becomes increasingly difficult for commissioners to provide high quality services, if they are not in touch with the experiences of the people using, and in need of them.
Service user experiences of specific conditions, care services and how they navigate care pathways need to be accounted for and understood when developing commissioning strategies. Even after commissioning decisions are made people’s experience of care services remain a key component in informing the quality of and access to the commissioned services themselves.
In 2013 Picker worked with two of London’s largest Clinical Commissioning Groups (CCGs) to improve primary care quality in the area by studying patients’ experience of access to local services.
Care user’s experiences are vital to ensuring good commissioning decisions
Although the objectives and approaches of each project differed, the findings revealed common themes such as appropriate communication, service flexibility, support and education, all playing a massive role in a patient’s choice to use, or in some cases, not use a service. Ultimately, a service being commissioned and “available” did not necessarily guarantee patient accessibility.
The first project revealed that, whilst on the surface the CCG was providing and tailoring services to each community group’s individual needs and requirements, when probed deeper there were many avoidable glitches in the details that were collectively causing fundamental roadblocks to the quality of care services available.
Translation services were a communication issue that affected two prominent ethnic communities. Participant data showed that 98% of one of the CCG’s ethnic groups spoke one regional dialect, however the translation services for these communities were provided in another. Though “quality care” was available to them, it was basically unattainable, as they were unable to understand the language it was provided in or read available translated health literature.
The results went on to reveal valuable insights for clinicians and commissioners as to the quality and effectiveness of the support services they were commissioning. Translators were perceived by the patients, (who were supposed to benefit from them), to be more of a hindrance than a help: Complaints included taking “too active a role in consultations” and “not relaying patient feedback correctly.” With reports of translators’ comments like; “don’t be too much trouble” and “you can only discuss one problem”, leaving patients’ feeling like a service burden, rather than a priority.
The CCG was also able to identify the support and potential training required for front line staff to improve care delivery. Effective communication and engagement were revealed to be affecting other patient group relationships and impacting service accessibility, especially for Lesbian, Gay, Bi and Transgender communities (LGBT). Some patients complained that they felt they had to “teach” their GP and other health care professionals how to speak to an LGBT person. This apparent stigma and discomfort often resulted in them going to their local LGBT forum for medical advice instead of, or before, visiting their GP directly. Even if LGBT specific services were apparently provided, they were not trusted. A similar story was evident for Mental Health services where service users report difficulty in speaking with their GP about mental health concerns and in securing referrals.
Measuring patients’ experiences to support a better understanding of care access
The second project looked at the use of unscheduled care services from the patients’ perspective. Both appropriate and effective communication alongside flexibility were revealed as a massive patient concern and a key motivation for the over use of unscheduled care services.
A lack of flexibility in obtaining appointments and the way that such appointments could be booked especially for “working people” were found to be key factors in why patients’ chose A&E or a walk-in centre over a GP. However some patients maintained they would use A&E regardless of other services available if they felt significantly concerned about their health.
Factors outside of the healthcare setting were also shown to impact burden on urgent care services and need to be addressed when commissioning care. This highlighted the need for the CCG to establish better links outside of a primary care setting and to utilise wider networks such as Health Watch to support education. For example a high volume of A&E referrals were found to be being made by local schools and this likely played a part in the number of inappropriate A&E referrals. From the results the CCG were able to see the need for better education around the purpose of A&E, and when and when not to attend.
However when a community service was well known and trusted it was seen as a first choice for patients, demonstrating the importance of not only establishing effective options for patients to access urgent care services but the fact that effective commissioning can have an impact in reducing burden on local A&E departments.
Of all the urgent care services in the CCG, a long-standing, local out-of-hours GP service was – excluding the patient’s own GP surgery – revealed to be the most widely understood and trusted service in the area. Quality improvement recommendations included expanding that model, by labelling walk-in centres with a similar branding, to help to build awareness of other available unscheduled care options. If awareness and trust of a particular service were not achieved the study showed that patients would bypass that service regardless of quality.
“Often healthcare providers think they know what patients want from a health and social care service, but often the gap between their perception and ‘getting it right’ is bigger than health professionals think.”
Dr Andrew McCulloch CEO Picker
In short, patient involvement in measuring quality improvement in healthcare can be the difference between getting the commissioning balance right and getting it very wrong.
Here are some key tips to effectively understanding and measuring peoples’ experiences of health & social care services:
- Ensure a rounded perspective
- Programmes should be designed to gather feedback directly from each care user group whenever possible. Questions should wherever possible have been cognitively tested with relevant care users. Programmes must also take into account that different care services may require different data collection methods.
- Be appropriate and engaging
- The appropriateness of the survey tools and questions we use significantly affects their potential to collect high quality experience data. If not appropriate for the audience, respondents may misinterpret the meaning of questions, be unable to give answers, and/or decline to give their feedback.
- Measure experience over satisfaction
- As in our work with adults, we have found that research with children and young people must aim to examine experience rather than simply measure satisfaction.
- Produce actionable results to advance healthcare quality improvement
- Results must be presented in a format and at a level that is useful to staff. Tables, charts and targets all have their place, but the focus on appropriateness and engagement applies as equally when presenting results to staff as it does when considering mechanisms to collect feedback from patients and service users.
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