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Are you ready for the Friends and Family Test?

March 9, 2013

The Health and Social Care Act (2012) comes into force on 1st April 2013. On that day, Primary Care Trusts will be abolished and replaced by new Clinical Commissioning Groups (CCGs) who will be responsible for commissioning and purchasing health care for their local populations. On the same day, the NHS Friends and Family Test (FFT) goes live across the whole country. Following its introduction, every inpatient and A&E attender will be asked, on discharge, the following question: ‘‘How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?‘ [They] will be invited to respond to the question by choosing one of six options, ranging from ‘extremely likely’ to ‘extremely unlikely” (direct quote from NHS Choices website). Co-incidence? Don’t be silly! The two events are inextricably linked by the present government’s not-very-well hidden agenda of opening up the NHS to competition.

The idea of using patient feedback as a tool to improve the quality of NHS care is a common-sense one: as long ago as 1998 the then Labour administration was promising that ‘Information about patients’ experiences of the NHS, captured through a new Patient Survey will form an important part of our overall assessment of NHS performance‘ (Department of Health, 1998). This early acknowledgement of the importance of patient opinion in service development translated into a programme of ‘National Patient Surveys’, which have run over the last decade or so. However, because only a percentage of patients was ever included, it arguably failed to establish itself as a routine and expected part of health-service user experience. Neither was it always very clear how Trusts made use of the information obtained through the surveys.

The present government’s far more determined efforts are driven by the need to provide a constant stream of feedback to local CCGs. NHS services which attract consistently negative comment may find that they are in line for closure, transferral to more distant NHS facilities or transferral to a profit-making private provider working under contract to the NHS. In some cases, it will be no exaggeration to say that respondents who decline to recommend their place of treatment may actually be accelerating its demise.

In this context it should come as no surprise that the government’s solution to the problem of identifying a suitable vehicle for the survey has been to turn to an off-the-shelf ‘product’ – the ‘Net Promoter Score’ – originally developed as a means of gauging customer loyalty, and simply re-brand it as the ‘Friends and Family Test’. Many commentators have pointed out the inappropriateness of applying this kind of model – and specifically the verb ‘recommend’ – to a socialised health care system where the majority of users have no choice about where they are treated. Certainly there are grounds for wondering whether the casual introduction of the language of consumerism is just another step along the road of ‘softening up’ the public to the idea of ‘choice’ and competition within the NHS.

Ahead of implementation, much of the criticism of the FFT has centred on its wording. There is undoubtedly scope for misinterpretation – for example, a patient might reasonably wonder why they would recommend a hospital on the South Coast to family who live in Scotland – but this is likely to be nothing more than the immediate reaction of someone who has never heard of the FFT and is seeing it for the first time. Once the test has bedded in (or the ‘softening up’ process has been successful) this kind of misunderstanding will almost certainly diminish.

A more pressing problem may be the representativeness of the people who choose to respond to the test. Participation will be voluntary. The Department of Health’s Implementation Guidance (2012) states that ‘face to face interviews should not be used due to response bias’ but in many of the data collection methods it does endorse (logging on to a website, calling a freephone number), the onus is on the respondent to take the initiative in replying. This situation may itself introduce bias by increasing the likelihood that only those with extreme views (good or bad) will bother to complete the test. As the Department acknowledges, data collection also presupposes a familiarity with modern technology and an ability to understand English. Trusts are expected to put in place strategies to reach user groups who do not fit this profile, but suggestions on how they should go about it are vague.

Also vague is guidance on how to include relatives of what the Implementation Guidance calls ‘palliative patients’. (It’s not even clear whether ‘palliative patients’ is a euphemism for ‘all patients who die in hospital’ or whether it specifically excludes the families of patients who die unexpectedly). This is a striking omission because it will only take one tactlessly-handled FFT request to spark a Daily Mail headline of the ‘Hospital Chumps asked if we would RECOMMEND ward where mum died!’ variety followed by a full-scale campaign against the entire FFT project (with the usual ghastly triptych of ‘Jobsworths’, ‘Bungling Bosses’ and ‘Callous So-Called Carers’ firmly in the dock). Just look at the mess we’ve got into with the Liverpool Care Pathway.

For nurses, the biggest impact of the FFT will come via the publication of its results, broken down by ward or department, on the NHS Choices website from July. Yes. That’s right. Statistics and (possibly) verbatim comments about the standard of care on YOUR ward will be available online, for ANYONE to view, from July this year. Advising providers on how to help staff cope with negative feedback is beyond the remit of the FFT Implementation Guide but it is absolutely crucial that Trusts use the three month window between the commencement of data collection and the publication of results to educate staff, correct any immediately apparent problems and set up leadership and support networks for those who work in under-performing areas.

The DoH is confident that the overwhelming majority of NHS services will receive high approval ratings and that this will act as a morale-boost. Inevitably however, some will do less well and it is probable that these will correlate with areas where nurses are struggling to provide a service in the face of inadequate staffing, increased workloads and unsympathetic managers. It’s unlikely that the much-vaunted spirit of transparency will extend to publication of individual wards’ staff-to-patient ratios or patient acuity figures alongside their FFT ratings, so when the public arrive on below-average performing wards full of anxiety and hostility after doing their online homework, it will be front line nurses who bear the brunt of it – even though the ward’s failings are not their fault. For some, this may just be the last straw. Let’s hope Trusts have thought it through.

Department of Health (1998) A First Class Service: Quality in the New NHS; London; The Stationary Office

Department of Health (2012) The Friends and Family Test Implementation Guidance; Viewable online at

Want to read more on this? Try It’s a really good short article by Chris Graham, Director of Surveys at the Picker Institute Europe.

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  1. Helpful articles etc | Patients4NHS

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