The NHS friends and family test rebooted: a vast improvement but it could be better
Since its pilot in 2011 the Friends and Family Test (FFT) has been charged with finding its way along a challenging and bumpy road, bordered by unreasonable expectations for its performance on one side, and eager anticipation of its failings on the other.
We have followed the FFT from its announcement as a “single measure of patient experience”, so we were waiting with baited breath to see NHS England’s review. So, has the review done enough to appease the test’s harshest critics? In short: there are a lot of positives, but the review stops short of fully addressing all concerns.
NHS England’s commitment to reviewing the test’s first six months of operation is a welcome signpost along the FFT’s troubled path. Its inheritance of the test clearly left it with a difficult hand to play, and its approach of engaging with, and more importantly listening to, both proponents and critics of the test in order to identify what’s working well and what could be improved suggests a much needed degree of pragmatism.
Clarity of purpose?
First for the good news. Critics have long said that one simple patient feedback tool cannot possibly meet the multitude of requirements previously demanded of it. And the review’s headline message that the test is most suitable as a tool for service improvement, rather than comparative performance monitoring, shows that NHS England have been listening. The further acknowledgement that the test’s relative results shouldn’t be used as a basis for performance related payments or publicly presented in a way that suggests comparability, also goes some way towards addressing concerns about FFT’s use in comparisons and restoring its credibility.
However, critics of the existing headline FFT score (based on the Net Promoter Score concept) are unlikely to embrace the news that it may potentially be replaced by an even more contentious hospital star rating system, akin to that used by Amazon and Trip Advisor. Not only could this encourage patients to make direct comparisons between hospitals on the basis of a tool that is ill-equipped to inform such insights, but more worryingly it could be detrimental to provider reputation and staff morale as some hospitals inevitably become saddled with negative ratings and low rankings.
Similarly, whilst the review acknowledges that FFT is best used for improvement and not direct organisation comparisons, NHS England finds itself in the tricky situation of still having to justify how it may be sensibly used to inform patient choice. Nowhere is this tension more clearly highlighted than in the following quote:
“in order for its use for public choice to be maximised, FFT data should be presented to the public in a much clearer and understandable manner, albeit one that does not imply direct comparability of FFT data between trusts”.
This leaves us contemplating how exactly the test’s incomparable data should inform our choice of provider?
How much impact has FFT had?
Next we’re left musing on the incremental benefits of the FFT. Some in the sector may raise an eyebrow at the factors identified in the review as determining the effectiveness of FFT as a feedback mechanism to drive local improvements, including for example the leadership and culture of considering patient experience data prior to FFT. Cynics may even raise the other eyebrow when reading that:
“in wards and departments that previously lacked a culture of collecting and responding to patient experience data, FFT may take longer to become embedded and used as effectively as possible”.
The review therefore raises big questions about the size of the FFT’s benefits in comparison with its costs, particularly when it acknowledges that more external support for larger scale data collection and analysis and potentially further technological investment may be required as the test is rolled-out further.
Clarity appears to come on the subject of the weight of expectation on the FFT, as NHS England suggests development of an information strategy which comprises the full set of complementary patient experience channels and tools. However, viewers of one of the videos that accompanies the review may be left with an uneasy feeling of deja-vu when NHS England’s National Director for Patients and Information tells us he believes the roll-out of the FFT later this year:
“will come to be seen as one of the most important turning points in the history of the health service”.
Whilst the value of the FFT should not be underestimated and one little test can undoubtedly achieve much, if there’s one take away lesson to be learnt from the first six months of its operation, it’s that we should also be aware of its limits. Many of the successes attributed to the FFT have resulted from small changes, from soft-closing bins to reduce noise on wards at night, to Marmite on the menu at breakfast. Not every change needs to be revolutionary for its impact to be real and worthwhile. In order to realise and celebrate the value of the FFT, we need to be proud of the little things it can do and stop asking it to do the big things that it can’t.