Patient satisfaction questionnaire surveys in the National Health Service, the effectiveness of the data and what they can demonstrate.
The National Health Service has faced various attempts at reform since the 1980s. These reforms have had differing objectives, such as improving efficiency, providing patients with greater choice as to the medical treatment they receive, or reducing the waiting lists for treatment. Some reforms have been motivated by practical concerns such as treating the greatest number of patients whilst other reforms have been politically motivated such as introducing an internal market. Traditionally the National Health Service was provider orientated rather than consumer or patient orientated in the way in which its services were provided. Patients were provided with the treatments to cure their illnesses and improve their health without any regard to whether or not they are satisfied with the level of service they have received. As will be discussed the National Health Service is probably the part of the public sector in Britain that has caused the most political controversy, the constant search to keep it working effectively without becoming prohibitively expensive. Governments and the opposition like to show that either the National Health Service is performing well or that it is performing badly. They have often been more interested in political points scoring rather than patient satisfaction. Patient satisfaction was never considered to be of paramount importance within the senior management of the National Health Service or the politicians, even though millions of patients received treatment or benefited from its services every year. A brief background of the way in which data was collected prior to the use of patient satisfaction questionnaire as well an explanation of the theoretical, ideological, practical and political changes that have impacted upon the National Health Service delivery of services since the 1980s are useful points of reference. New Labour has also sought to reform the public sector including the National Health Service since 1997. The patient satisfaction questionnaires can be regarded as an essential part of New Labour attempts to bring good governance to the National Health Service.
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The patient satisfaction questionnaires are just one method in which performance of the National Health Service can be measured. Most of the other means of measuring the National Health Service actually predate the start of the patient satisfaction questionnaires from 1998. As will be outlined below there are various areas in which the data obtained from patient satisfaction questionnaires may or may not be considered to be effective and what that data is supposed to demonstrate. Arguably, the results and the data from the patient satisfaction questionnaire can demonstrate strengths, weaknesses, improvements, or deterioration in the service provided to patients through the patient satisfaction questionnaire. The data from patient satisfaction questionnaire is to be found in the Department of Health annual reports, Healthcare Commission reports and reports from individual health trusts. The effectiveness of the patient satisfaction questionnaire acting as a means for patients to be able to complain about, compliment or suggest improvements to the level of service they have received from the National Health Service will also be discussed. The effectiveness of the patient satisfaction questionnaire as a means of making the National Health Service accountable to its patients will be considered, whether it promotes patient care is just merely lip service to the concept of a patient focused service. Switching focus to the needs or views of patients would be a fundamental shift. There are currently two different types of patient satisfaction questionnaires, which the Department of Health commissions to obtain patients opinions of the services provided by the National Health Service. The main patient satisfaction questionnaires are carried out by the Healthcare Commission whilst a smaller patient satisfaction questionnaire is carried out twice a year (in the spring and the winter) by MORI, more widely known for conducting political opinion polls. There are different arrangements for Scotland, were different departments and organisations are responsible for running patient satisfaction questionnaires (Department of Health / MORI, 2004 p. 1). The majority of patient satisfaction questionnaires are carried out at the level of the individual health trust units and then collated by the Healthcare Commission, which then publishes the overall results. Local questionnaires are paid for by individual health trust units whilst the majority of national questionnaires are funded from central National Health Service funds (www.healthcarecommission . org).
Government departments, local authorities and public sector service providers such as the National Health Service produce what can seem to be endless amounts of data whilst carrying out their daily tasks or services. In the National Health Service all sorts of data is collected, such as the number of patients treated, the cost of each type of medication or operation and even which patients are most likely to be better suited to receive medication and operations. That data can be very useful in determining how the National Health Service rations out its resources and auditing that spending. However such data was not able to demonstrate how patients regarded the National Health Service or they had any complaints, compliments, or suggestions on how to improve its services. Data can be used to make service provision more effective, used to make the government of the day look good or bad depending on how it was used, and form the basis of articles in the press and the media. Prior to the patient satisfaction questionnaire, National Health Service data was available to be used to make the command structure of the service work better. The National Health Service was not run on the basis of maximising patient satisfaction, it was run from government command and is still tasked with delivering a free health service based on treating patients equally on the basis of need (Fisher, Denver & Benyon, 2003 p. 301). The Department of Health states that: “Surveys of patients are designed to provide detailed feedback to healthcare providers about the experiences and views of patients”. Questionnaires were seen as ideal method “to furnish information that the Healthcare Commission can use to access the performance of healthcare providers; and to monitor the experience of patients at a national level (Department of Health, 2004).”
The National Health Service along with similar health services has carried out research to evaluate individual treatments, evaluate the care available to patients that suffer from specific ailments or conditions, the evaluation of individual hospitals or clinics, plus finally evaluating ways to make government funding go further. Within the National Health Service little thought was given to the opinions or satisfaction of its patients, it was widely assumed that an effective National Health Service would treat more people, the more people that were quickly and effectively, then more of them would be satisfied patients. Therefore more patients would be satisfied once they had received the treatment they needed and hopefully made a full recovery. Perhaps patient satisfaction questionnaires could have been developed earlier, yet prior to New Labour gaining power there was no significant political support for such a step to be taken. Patient satisfaction questionnaires have also only become practical in terms of time and expense due to advances in information technology, advances that have increased both the expense and patients expectations of the National Health Service. However advances in technology and treatments also meant that the National Health Service treated more patients successively than before which increased the demand made upon on its resources and its budget. National Health Service patients and its staff seem to concentrate on were its performance is weakest rather were it is strongest. Perhaps they feel such an approach increases the case for giving the National Health Service more staff and funding while emphasising its strengths does not (Clarke, 2001 p. 262).
The data obtained from counting the number of patients seen, the amount of drugs prescribed, or the overall costs of different operations is by and large objective, such data can be used to determine the best way of using resources to maximise the number of patients treated. However what such data does not show, and it is not designed to demonstrate is the level of patient support for the National Health Service and patients’ views on how to make the National Health Service more responsive to their needs. Politicians, senior civil servants in the Department of Health (in its various guises and titles), and the senior management have always seemed to sense the attachment of the British public towards the National Health Service. Politicians prior to Margaret Thatcher played it safe by not tampering greatly with the structure or services of the National Health Service to protect their chances of electoral victory. In one respect questionnaires in the form of political opinion polls showed there was a high level of general satisfaction with the National Health Service, data that reinforced the politicians view that the National Health Service should be left alone. However aside from people wanting public spending on health to increase and wanting to see waiting lists reduced such opinion polls gave scant levels of data with regard to actual patient satisfaction with the National Health Service (Fisher, Denver & Benyon, 2003 p.300).
Ironically it was the Conservative governments from 1979 that altered the way in which patient satisfaction with the National Health Service was considered. That change was inadvertent, as the Thatcher government aimed to make the National Health Service more efficient by introducing elements of the private market into it (Abercrombie, Hill & Turner, 2000 p.161).
From its very inception in 1948 the National Health Service had to balance high patient expectations with a limited budget. The National Health Service did manage to deliver a cost effective and generally equitable service that had to ration its resources and put provision ahead of satisfaction. That rationing seemed more acceptable to the general public as potential patients because the decisions over who received treatment or not was made by doctors rather than politicians or civil servants in the Department of Health (Fisher, Denver & Benyon, 2003, p.300). The Thatcher government was not able to dismantle the National Health Service and it was only able to slow down the increase in health spending rather than reduce it. An internal market was introduced that aimed to improve patient service as the National Health Service was split into districts, the more effective or least busy districts would help the less effective or busier districts (Leathard, 2001, p.103). The Conservatives further reformed the National Health Service by setting up healthcare trust units that were intended to further devolve health service provision, and allow each unit to spend its allocated funds on treatments, medication and staff in any way they wished to (Clarke, 2001, p.260). However, the most relevant reforms introduced by the Conservative government of John Major was the Citizen Charter. The Citizen Charter for the first time allowed National Health Service patients to complain about service provision and try to improve that service and therefore patient satisfaction (Hughes, 1998, p.27).
The Citizen Charter being established also meant that it was easier to collect data about how many people were unhappy with the National Health Service. The Citizen Charter meant that the National Health Service along with other public sector organisations had to publish standards that its services had to achieve. The National Health Service had to publicise those standards and ways in which it hoped to achieve them (Hughes, 1998 p. 28).
Since being elected in 1997 New Labour governments have attempted to increase the level of provision of services by the National Health Service whilst attempting to increase the influence of patients in that service provision. New Labour has the same problems with the National Health Service as its Conservative predecessors and its eventual successors. New Labour did end the internal market, yet retained the health trust system. New Labour introduced the patient satisfaction questionnaire to increase patient input into the way the National Health Service is run and services are provided. However, New Labour just like the Conservatives had not been able to resolve how to provide an effective, yet essentially equal service that allows patients to influence how they are treated. No government can escape the issues that face the National Health Service of providing adequate funding and deciding which treatments and operations have to be rationed due to their higher costs or lower effectiveness. Overall, the National Health Service has been remarkably successful. Yet success increases expectations and the reality of a rationed service in which the patients have little or no wait for treatment and do not have their treatment turned down on the grounds of costs will be more satisfied than those that have to wait for treatment will. Of course, the only way in which any patient could guarantee being able to receive the treatment they need with their wishes being of paramount importance is by having that treatment carried out in the private sector. Private patients would not obviously take part in the patient satisfaction questionnaire. If private patients are not happy with the service they have received they can simply go to another service provider. Dissatisfied National Health Service patients can complete the patient satisfaction questionnaire, write to their MP and complain to the particular health care trust that provided their treatment, many cannot, however, afford to have private treatment (Fisher, Denver & Benyon, 2003, pp.304-5).
The data that is provided by the patient satisfaction questionnaire could be useful in that it can show which health care trusts and hospitals are perceived to be providing a good service and which ones are providing a poor service. Since the patient satisfaction questionnaires have been in operation they have indeed demonstrated that strong and weak areas of service provision combined with stronger and weaker performing health service providers. The responses provided by patients are subjective in nature yet such responses are a means to drive improvements to service provision. It a sense it does not matter that patients’ opinions are subjective as the whole point of the questionnaires is to demonstrate patient perceptions and opinions. The data obtained from the questionnaires can be more objective in nature depending on which questions are asked and which information is asked for. The questions conducted by the Healthcare Commission usually have respondents from each trust whilst MORI aims to have at least 1,000 respondents for its tracker survey of patient expectations and experiences. MORI claims that its questionnaire findings are as accurate as its opinion polls and election predictions (with an error margin of 3%). The MORI surveys are aimed at gaining an insight into people’s perceptions and experiences of the National Health Service, whilst the patient satisfaction questionnaire conducted by the Healthcare Commission goes into greater detail (Department Of Health / MORI, 2004, p.1).
It has to be remembered that patient satisfaction questionnaire are not intended to question everybody that has been a National Health Service patient in any given year. That would be too time consuming and would probably not bring any further worthwhile gains in effectiveness to justify the extra time and expense compared to the way the patient satisfaction questionnaires are currently carried out. The accuracy and effectiveness of the patient satisfaction questionnaires is increased by the fact that they gather opinions from patients throughout the country, which allows variations in the standard of services to be demonstrated and to a certain extent explained. Variations in the standards of services can be explained by how individual healthcare unit trusts spend their allocated budgets, which means that some treatments are widely available across the country whilst being able to receive other treatments depends on were patients live in the postcode lottery (Newman, 2001 p.91). Research has shown that peoples health is poorer as they have less money and are less educated or unable to take preventive steps to avoid illness, whilst healthcare trust units that are in areas of greater deprivation have a greater number of patients to treat. People that are wealthier tend to live longer, whilst healthcare trusts in more affluent areas have a lower demand for treatments. The inequality of healthcare provision whilst lower in the National Health Service still exists and has been shown in studies prior to the adoption of patient satisfaction questionnaires (Abercrombie, Hill & Turner, 2000 p. 339). It should come as no surprise that although a majority of patients included in the patient satisfaction survey are content with the National Health Service there are groups and individuals that believe the service does not treat them equally. Overall satisfaction with the National Health Service, especially with its GPs remains high, with around 75 % of patients are satisfied with the service they receive from their GP. Patients are it seems beginning to be more satisfied with the part of the National Health Service that always seemed to cause the least amount of satisfaction, the Accident and Emergency departments of hospitals (Department of Health / MORI, 2004 p. 11). The same questionnaire showed that 62% of the patients that took part in the questionnaire were happy with the level of service they had received from the National Health Service. That is a figure that is around the average for such questionnaires, yet seems to have increased since the questionnaire process started (Department of Health / MORI, 2004 p. 8).
Improvements in service delivery are not uniform across the whole of Britain, with some patients and patient groups feeling more excluded and dissatisfied than the majority of patients seem to be. The move to a patient led National Health Service will not be quick, or evenly balanced out across the country, as every healthcare trust retains autonomy over their budgets and set their own spending and treatment priorities. That is a conclusion that has been amply demonstrated by patient satisfaction questionnaires that has prompted action from the Department of Health and the National Health Service to make improvements go right across the National Health Service (Healthcare Commission, State of Healthcare 2005, p. 5).
Patient satisfaction questionnaires have demonstrated that patients usually have highest levels of satisfaction with their local hospitals, their local GPs, and their local clinics. Patients generally support their local health unit trusts more than the National Health Service itself as a whole. Patients are more likely to trust their local health trust units to deliver a good, effective and equitable level of healthcare services. Patients, as the patient satisfaction questionnaires tend to demonstrate do not always trust the government’s intentions towards the National Health Service. Added to that mistrust, a minority tends to believe that there too many bureaucrats within the Department of Health and the National Health Service instead of frontline medical staff. Patient satisfaction questionnaire frequently demonstrate that the government increasing spending on the National Health Service will raise patient expectations, although expectations are likely to increase at a faster rate than actual improvements to the service provision of the National Health Service can become noticeable. Increases in spending do not automatically lead to tangible yet are more likely to keep patients satisfied than if there is a widely held perception that funding and services have been cut. Patient perceptions about the National Health Service can and are changed by stays in hospital as well media and press reports. Generally lack of resources and funding is considered to the main concern for patients. However other concerns such as the lack of doctors and nurses plus the lack of cleanness in hospitals are often expressed in questionnaires (Department of Health / MORI, 2004 p. 15).
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The usefulness of patient satisfaction questionnaires since 1998 and their effectiveness has been enhanced by the adaptability of the questionnaires used. Although the patient satisfaction questionnaires have not all being provided by the same companies they have all been approved by the Department of Health and the Healthcare Commission. The availability of easily adaptable computer packages has greatly enhanced the adaptability of the patient satisfaction questionnaires. It is possible for the Department of Health and the Healthcare Commission to have questionnaires as large or small, or as complicated or as simple as they want. That adaptability means that they can build specific questionnaires at the request of the government as and when the need arises. Patient satisfaction questionnaires have been able to provide more specific data on more specialised areas of healthcare provision when they have been carried out on specific groups of patients with common ailments or conditions, or on particular types of institutions within the National Health Service. For instance there has so far been two specific patient satisfaction questionnaires concentrating on GPs or surgeries in 1998 and 2002. A more recent and presently ongoing patient satisfaction questionnaire is the 2006 survey of patients that use institutions specialising in mental health problems. The adaptable nature of patient satisfaction questionnaires has proven to be one of their greatest assets. If one general questionnaire finds that a particular group of patients is markedly more dissatisfied than the rest of the patients questioned a further questionnaire can be organised to find more detailed data and information from such groups. Similarly, if patients in a certain geographical area or attending a specific type of healthcare trust are less satisfied than other patients they too will be questioned in greater depth in subsequent patient satisfaction questionnaires (www.nhssurveys.org).
Patient satisfaction questionnaires would be less effective and demonstrate relatively little if they were not adaptable. Patient satisfaction questionnaires had to be adaptable to be effective in surveying the opinions and perceptions of patients from over 300 primary care trusts besides the numerous other forms of National Health Service trusts. The complexity of the National Health Service continues to increase as health services are being increasingly provided in conjunction with voluntary and private sector organisations from outside the National Health Service. Patient satisfaction questionnaires could in theory be extended to cover those external organisations. The Healthcare Commission already has to inspect some of those organisations to ensure they meet statutory requirements when they provide health services (Healthcare Commission, State of Healthcare, 2004 p. 16).
It can be argued that patient satisfaction questionnaires have proved capable of being catalysts for promoting further changes to service provision in the National Health Service. Patient satisfaction questionnaires have arguably provided data that has to increase inspection in certain areas of the National Health Service that did not usually receive as much funding or media coverage as other parts have done. More specifically patient satisfaction questionnaires helped to demonstrate problems with “maternity and mental health services, particularly mental health services for older people.” Data and information gained from patient satisfaction questionnaires have contributed to the Healthcare Commission annual health checks to cover the entire National Health Service, which started in 2005 (Healthcare Commission, State of Healthcare, 2005 p. 36).
Whatever the merits of patient satisfaction questionnaires there are some things that its effective data and the information it demonstrates will not be able to achieve. The data will not alter the fact that the National Health Service as a whole and right to its individual trust units has to ration the services and treatment that it can provide. The treatments and services that are fully provided and those that are rationed or even not available at all will vary from unit to unit. Effective treatment and therefore subsequent satisfaction or dissatisfaction with the National Health Service individual patients will be. To some extent unavailability of treatments can be reduced as trusts can pay other trusts to provide services they cannot and vice versa Newman, 2001 p. 51). New Labour has also been concerned that patient satisfaction questionnaires would not provide enough of an incentive for failing or struggling trusts or service providers to improve their levels of service. Patient satisfaction questionnaires could certainly provide evidence of failing parts of the National Health Service, especially when combined with other inspections of the National Health Service carried out by auditors. There is however contradictions within New Labour’s policies towards the National Health Service that could impact on the effectiveness of the data collected from patient satisfaction questionnaires. If increasing patient satisfaction was the sole non- – medical objective that all parts of the National Health Service had then the data and information demonstrated by patient satisfaction surveys would by effective and of great significance. Health trusts have contending priorities though, such as balancing their budgets or having to lose beds and medical staff or deciding which treatments and operations are the most effective ones to gain impressive performance indicators (Newman, 2001 pp. 91-2). Other parts of the National Health Service or Department of Health can inadvertently affect patient satisfaction. A good example is the National Institute for Clinical Excellence which determines which drugs and treatments are safe enough to fully licensed for use within the National Health Service. Safety trials can be time consuming, whilst until treatments are fully licensed their increased cost and reduced availability deters health trusts from using them. These delays have understandably lowered patient satisfaction especially amongst those who are denied possibly life saving treatment because of it (Newman, 2001 p. 89).
Perhaps the biggest challenge to the future of patient satisfaction questionnaires would only occur should or if the Conservatives regained power, they would not necessarily believe that the data and the information demonstrated from patient satisfaction questionnaires would still be needed. The Conservatives would not necessarily care about what patients think about the National Health Service although even during Mrs Thatcher’s term as Prime Minister they were not able to reverse spending on the National Health Service. The Thatcherite fringe of the Conservative Party would have liked to expand the private health sector in Britain still further, seeing it as a way to reduce the size of the National Health Service. As such the best way of increasing patient influence was to increase choice and competition within the National Health Service although it would remain less than in the private sector (Fisher, Denver & Benyon, 2003 p. 304). How the Conservatives regard patient satisfaction questionnaires could depend on how influential David Cameron is in moving the party towards the political centre. Should the Conservatives decide that they would retain patient satisfaction questionnaires then it could be assumed that their future is assured meaning that their data will remain effective and their demonstrations of patient feelings could be guaranteed a hearing over the long-term.
To conclude patient satisfaction questionnaires can offer useful data about the level of services provided by the National Health Service and the experiences or perceptions of patients with regard to those services. The patient satisfaction questionnaires to a large extent demonstrate that they can obtain the information from patients that the Department of Health and the Healthcare Commission are seeking. If the patient satisfaction questionnaires are not providing enough information then they will be amended for the following year. Patient satisfaction questionnaires can be a useful measure of the services that the National Health Service is delivering well or those that it is not providing so well. In other words, the patient satisfaction questionnaire is a means of demonstrating the standards being achieved by the National Health Service, where those standards are highest, and where those standards are lowest. The patient satisfaction questionnaire produced for the Healthcare Commission can provide quite detailed data on all the health trust units across the country, and can identify achievements and failures. The patient satisfaction questionnaire produced for the Department of Health by MORI is a useful guide to overall patient satisfaction and perceptions of National Health Service performance every spring and winter. Patient satisfaction questionnaires have the advantage of being highly adaptable. The findings and data from one questionnaire can justify the Healthcare Commission starting follow up patient satisfaction questionnaires. Follow up questionnaires can be used to obtain more specific data and information to resolve problems or reduce dissatisfaction with parts of the National Health Service that are not up to the desired standards of service provision or failing particular groups of patients. Patient satisfaction questionnaires have demonstrated areas in which patient satisfaction and even the level of treatment and service has not been good enough such as maternity and mental health services. Patient satisfaction questionnaires are only effective means of collecting data and demonstrating any information gained if the government is genuine in its desire to shift the emphasis in administering the National Health Service in the interests of its patients rather than those that provide those health services. However it remains unlikely that patients will ever have the dominant influence upon how the National Health Service is run, political, medical and economic factors will more than likely continue to have greater importance in how the National Health Service is organised. New Labour appear to be committed to increasing the importance of patients in contributing to how decisions concerning the services provided by the National Health Service. The further that process goes the more important the data from patient satisfaction questionnaires will become. That will because those questionnaires will be able to demonstrate a greater contribution from patients to the running of their health services, they will demonstrate that patient power can be a major influence on the National Health Service.
Abercrombie, Hill & Turner, (2000) Penguin Dictionary of Sociology 4th edition, Penguin, London
Clarke A, (2001) The Sociology of Healthcare, Prentice Hall, Harlow
Department of Health, National standards, local action, 2004
Department Of Health / MORI – Public Perceptions and Patient Experience of the NHS: winter 2004 Tracking Survey Summary Report & Computer Tables, Research Study Conducted for The Department of Health, November – Dece
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