11 August 2016
Jane Mordue, Healthwatch England

Jane Mordue

Interim Chair
Healthwatch England

We invited Jane Mordue of Healthwatch England to comment on our latest indicator update, which focused largely on data relating to inpatient experience. 

Healthwatch England is the national consumer champion in health and care, here to ensure the voice of the consumer is strengthened and heard by those who commission, deliver and regulate health and care services.

We do this through our support for and leadership of local Healthwatch, commissioned by each of 152 local authorities. Our network engaged with more than 385,000 people last year, finding out about their experiences and views through the teamwork of 6,000 volunteers, visiting 3,500 services and publishing 1,450 reports.

That’s why I’m so interested in the latest QualityWatch analysis of trends in patient experience, which I’m sure will generate discussion within the Healthwatch network as well as the wider health and care community. I think it highlights three important issues and presents two challenges to those commissioning, delivering and evaluating care.

Recognise achievement but don’t rest on your laurels

There’s clearly a good news story in the trend data on people’s overall rating of their care. The national inpatient survey asks people to rate their overall care experience on a 0 to 10 scale (0 being a poor experience and 10 a very good experience). In 2014 and 2015, 89% rated their care at 6 or above – up from 87% in 2012 and 2013. Almost half of respondents rated their care at either a 9 or 10 in 2014 and 2015.

These figures chime with what people tell local Healthwatch about the care they receive: most people have a good experience and value their services.

But no-one wants or deserves to be one of the unhappy or badly-served minority, no commissioner can be content with even a low proportion of services failing to achieve their intended outcomes, and no professional can rest easy knowing that some patients’ care has fallen short of what is required.

Everyone involved in planning and delivering care knows that things are going to become still more challenging in the medium term. People tell the Healthwatch network that they understand and acknowledge this. They are ready and willing to take more responsibility for their own health and prepared for significant changes to the way services are organised.

But that requires managers and professionals to hold up their end of the bargain. The key to breaking down some of the most persistent barriers to consistent excellence will be to really drill down not just into data on patient flow and throughput targets but into the insight to be gleaned when you enable people to tell their stories, as local Healthwatch do.

An increasing number of key individuals have been realising that thorough, consistent, genuine patient engagement is like panning for gold. If the question is how health services can make the next upward step in patients’ experience of care, the answer lies in understanding what would have made things better for those who aren’t rating their care at 9 or 10.

Principles can and should drive practice

When Healthwatch England was established, we started out in 2013 by finding out what really matters to people. The analysis of patient experience that QualityWatch has delivered shines a light on several of the key principles we identified.

People told us they want high quality, safe, confidential services that treat those who use them with dignity, compassion and respect. They asked for clear and accurate information that they can use to make decisions about health and care treatment. It’s also important to people to be equal partners in determining their own health and wellbeing, with the right to be involved in decisions.

The inpatient survey questions that map to these concerns and aspirations should be at the forefront for anyone trying genuinely to gauge whether the culture of our services is driving patient experience in the right direction.

I’m pleased that the proportion of people who definitely feel they have been involved in decisions about their care and treatment has increased from 53% in 2005 to 60% in 2015, and that the proportion who felt they had not been involved decreased slightly to 9% in 2015 from 11% in 2005. This isn’t yet enough of a shift but it’s an important move forward.

However there’s been little difference in people’s experience of receiving information about their condition. While 8 out of 1o people feel they have received the right amount of information about their condition or treatment, this has not changed significantly from 2005 to 2014. Across that period, one-fifth of respondents felt they did not receive enough information and just 1% felt they received too much. These figures are consistently less positive for A&E departments.

It’s also interesting and telling to see that while overall people feel they are treated with dignity and respect, there are some real challenges in relation to privacy, especially in A&E services.

Focus on the discharge fundamentals

The Healthwatch network has undertaken substantial work on people’s experiences of discharge. Our Safely Home report reflected the experiences of more than 3,200 people, gathered through 101 local Healthwatch. Amongst our findings, we identified that people expect:

- To be treated with dignity, compassion and respect;

- Their needs and circumstances to be considered as a whole – not just their presenting symptoms;

- To be involved in decisions about their treatment and discharge;

- To move smoothly from hospital to onward support available in the community; and

- To know where they could go for help once discharged.

The historical intractability of the discharge challenge is reflected in the QualityWatch analysis. Over the decade a substantial proportion of inpatients asked said that they were not told about medication side effects to watch for once they went home. This was true for 41% in 2015.

It’s encouraging that there has been a statistically significant increase in the proportion of respondents who were told about danger signals to watch for after discharge. But in 2015, 35% were still not warned about the danger signals at all.

There has also been a statistically significant increase in the proportion of respondents told by staff who they should contact if they had worries about their condition or treatment after discharge. This increased from 76% in 2005 to 78% in 2014, where it remained in 2015, but the work now being undertaken across the system to improve discharge needs to drive these figures still higher.

A chance to tackle the twin challenge

The QualityWatch analysis is forced to focus on inpatient data after 2011, when the outpatient survey was discontinued and some of the questions integrated with the inpatient survey. The drivers for the focus on inpatient experience may be understandable but this change has contributed to a situation in which too high a proportion of patient experience information, including the Friends and Family Test, delivers a snapshot at the point of care or immediately afterwards, rather than a longer-term picture of overall patient experience and outcomes.

The challenge for those measuring and evaluating care is how, in a financial environment which will not support ever-growing numbers of surveys and research projects, to really capture an overview of how patients are experiencing care – including once they have been able to reflect upon it.

The challenge for those delivering that care is how to make a real gear change in patient experience by understanding what lies behind the headline figures.

You won’t be surprised if I say how firmly I believe that the Healthwatch network is well placed to be part of the solution to both of these challenges. We’re here and ready to work with all those who want both to understand and to improve patient experience.

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