1. 1 Jonathon Carr-Brown, Managing Director Patient Insight and Service Improvement Version 1.0 1 st October 2013

2. 2 Purpose How does NHS Choices collect patient insight? How does this inform service improvement? How does this inform patients and the public?

3. 3 Background The NHS Choices website currently gives the opportunity for NHS customers to give feedback on their service experiences through ratings and comments Current rate of posts is 7,000/month which has doubled since the start of the year On-line feedback appears broadly in-line with other service sectors that encourage customer comments and is similarly skewed towards younger, female, higher SEGs.

4. 4 Almost half (45%) are now aware of patient commenting NO = 55% YES = 45% AWARENESS Base: Total sample: 928 USED (Before today) Once 2-3 4-5 5+ Never used it = 24% = 25% = 5% = 8% = 38% Were you aware of the patient feedback feature on NHS Choices before today? Were you aware of the patient feedback feature on NHS Choices before today? How many times have you used the patient feedback feature before? How many times have you used the patient feedback feature before? Base: Total sample: 419 +19% -19% +7% +4% +9% Total 2013: 62% 2011: 43%

5. 5 Comments Increasing Number of comments posted

6. 6 Big Unreadable Table Comments Jan-12Feb-12Mar-12Apr-12May-12Jun-12Jul-12Aug-12Sep-12Oct-12Nov-12Dec-12Jan-13 Hospital 69377098390896510909169379259528887211435 GP 1742174722872096222329231967168316361928190113952764 Dentist 5065898087318187647157427167808015611142 Pharmacy 353057505775627463754978153 Optician 81223189121713914201429 Total Comments2984314841583803407248643677344933493749365927695523 Visits14503400138312661461643114301680158889621560550916028188159679221639421619751209197977221929277927311916 % of Site Visits0.0206%0.0228%0.0284%0.0266%0.0256%0.0312%0.0229%0.0216%0.0204%0.0190%0.0185%0.0144%0.0202%

7. 7 Recent Research Findings  ‘Feedback’ is defined by the general public by organisations like Amazon and Ebay - They do not understand the benefit of providing feedback within the NHS  There is no clear motivation for NHS Users to provide feedback on services - They do not believe patient feedback can influence change or help patient choice within the NHS  A Telephone Feedback Line will bring in some additional commenters - But without communicating how and why consumers should use it, it is unlikely to reach a wider audience

8. 8 What’s the Issue NHS customers, accept, in principle, that a similar model for logging and posting customer feedback and reviews could be established for NHS services. In practice, this is inhibited by fundamental perceived differences between an NHS provider/patient relationship and a commercial supplier/purchaser relationship. Patient/NHS partnerships have stronger emotional and personal elements that do not fit neatly into the familiar feedback model. There is a need to educate NHS users of the end benefits of sharing and using patient comments to encourage participation. Expectation of achieving service improvements via patient feedback is currently low. There is currently low perception of patient choice within the NHS that will drive customers to search or post feedback. There is a strong belief that choice of GP and hospital is beyond their control therefore there is no recognised requirement to search for reviews and recommendations.

9. 9 Feedback = Commercial Websites Used to check out goods before purchase: More reading than posting feedback Providing feedback fundamental to buyer and seller ratings. Incentive to feedback Useful research tool. Exceptional experience or wish to ‘balance’ negative comments triggers posts Feedback/reviews part of a website culture High awareness even among ‘non-commenters’ Definition and credibility of ‘feedback’ varies according to the organisation that requests it. Customers are more likely to engage where feedback is considered to be intrinsic to the customer experience and benefits, either personal or for the wider community, are recognised

10. 10 Engagement in a customer feedback loop depends on a persuasive reason to participate What will be achieved? Who will benefit? Change in service Change in behaviour Self All users/customers Unlike complaints, no hard evidence of change or benefit is required by consumers to drive engagement, but motivation to engage must be credible as well as persuasive Organisation Compensation/reward Altruism - helping others Develops customer/supplier relationship Key Drivers - Belief that feedback will have impact is important Help shape future experiences Encourage/discourage use That’s what you hope isn’t it? If you’re giving feedback there’s going to be a reaction: something’s going to happen (G4: non-commenters 40+ y/o)

11. 11 NHS customers have some difficulty in understanding drivers for feedback in the context of NHS services What will be achieved? Who will benefit? Change in service Change in behaviour Self All users/customers Low belief in being able to influence change within the NHS is a major barrier to engaging in feedback with NHS services Organisation Best achieved via personal complaint/thank you not feedback ‘ An ideal’ but doubt relevance of personal experience to wider NHS community Doubt that NHS organisation will be able to effect change based on feedback Key Drivers Customers currently feel influencing change is beyond their control Low awareness and credibility of choice within NHS services Your relationship with the NHS isn’t a purchasing relationship; it’s not about spending money, it’s about being treated (G2: non-commenters ≤40 y/o)

12. 12 NHS customers’ deep affection for the NHS inhibits willingness to give negative feedback Far more leeway allowed for delays and inconvenience than in commercial customer/supplier relationships Concern that any criticism will impact on their future use of NHS services Communication with the NHS services is generally triggered by a serious ‘complaint’ requiring action and a satisfactory resolution Response to both is personal and directed Older NHS customers, in particular, do not yet understand the value of ‘constructive criticism’ in the context of shaping improvements in ‘their NHS’ NHS service users require educating of the benefits of ‘constructive criticism’. There is low acceptance that by sharing experiences they have the power to shape the future of ‘their NHS’ I couldn’t go and complain to my doctor… there’d be this friction between us (G3:commenters 40+ y/o)

13. 13 Customers are happy to give positive feedback, but currently view this as a personal transaction between patient and service provider Low levels of expectation of NHS services (mainly hospital and GPs) means that when services go well it is ‘as it should be’ ‘Customer delight’ when services far exceed expectations is generally rewarded in person to the individual provider Older NHS users, in particular, recognise the power of a ‘thank you’ but are the most likely to reward providers either verbally or with a small gift But recent potential closure of local services has motivated some (younger) customers to add their support on-line – a wish ‘to be counted’ among other supporters The general public retains a strong affinity to ‘their NHS’ but positive interaction is usually directed at a personal, local level. Customers need to be persuaded that sharing their positive experiences more widely can benefit the broader community of NHS users I just wanted to give a little support to them because obviously they are facing difficulties at the moment (G1: commenters ≤ 40 y/o)

14. 14 So… Feedback, as understood by the general public, does not currently fit naturally within the NHS space Not a commercial customer/supplier transaction Most experiences of NHS services are both personal and emotional Low expectation that feedback will result in changes to services Awareness and belief in ‘consumer choice’ within NHS services is low NHS customers doubt credibility of ‘end benefits. Neither assisting others with consumer choices nor driving improvements are currently seen as achievable outcomes Who will be interested? What will it achieve? It’s a bit different with the NHS because you can’t pick a hospital (G2: non-commenters ≤ 40 y/o) For a service where I know the people personally then I would rather say thank you personally (G4: non-commenters 40+ y/o)