9 March 2018
Glenn Robert

Glenn Robert

Professor of Health Care Quality and Innovation
King's College London
Jocelyn Cornwell

Jocelyn Cornwell

Chief Executive
The Point of Care Foundation

The ‘Friends and Family Test’ is a long-established measure collected across the NHS which asks whether patients would recommend services to their loved ones. We have occasionally referred to it in our research. Recently the test came under public scrutiny by health professionals researchers interested in quality improvement. Here, two critics of the test explain why they think it should no longer be compulsory for all Trusts.


We recently wrote an editorial in the British Medical Journal with Nick Black which attracted as many responses as any editorial in the last 12 months. The topic? The ‘Friends & Family Test’ (FFT). Initially implemented just in acute Trusts in 2013, the FFT is a measure that is now collected in every NHS trust in England. The main question in the FFT is “How likely are you to recommend our service to friends and family if they needed similar care or treatment?” and respondents can rank their answer from “extremely likely” to “extremely unlikely.” Our argument? That the mandating of the FFT should now end.  

Here we wish to reflect on the responses prompted by the editorial by highlighting three aspects of the ongoing (perhaps never-ending?) story of the FFT which serve both to amplify our specific arguments and raise broader issues relating to the measurement of quality in the NHS.

Cost of implementation

Firstly, the FFT is an example of how difficult it can be for policy makers to stop mandating the collection of a measure once they have started. The FFT is not just any quality measure. It is the ‘biggest form of patient opinion in the world’; over 30 million pieces of feedback and counting have been collated centrally and that figure increases by 1 million every month. But is it - as one of the responders to our editorial commented - a ‘classic example of how to hit the target and miss the point’?

Don Berwick argues in the Journal of the American Medical Association that ‘the volume and total cost of measurements currently being used and enforced in health care [should be reduced] by 50% in 3 years and by 75% in 6 years’; this would ‘restore to care providers an enormous amount of time wasted now on generating and responding to reports that help no one at all.’ (Berwick was not specifically referring to the FFT here - he was writing in the context of US healthcare - but he could well have been).

But through what process could such striking reductions be achieved? Tantalisingly, a consultation on the future of the FFT in England has recently been announced. It encompasses all aspects of the Test (the question, the timing, the format); everything is up for grabs. Except the mandate. That has to stay. So just why do policies like the FFT accumulate? And if they fail to achieve the goal, why cannot they be stopped or withdrawn?

One responder may have hit the nail on the head when she likens the enforcement of the FFT to ‘just handing out surveys to make us feel like we are doing something. We might feel better for it but do patients and carers share that view?’ And perhaps ensuring statistics are at hand to enable statements of the ‘96% of patients recommend this service’ variety to be made is just too tempting? All this despite the costs and the complex and burdensome flows of data collection and analysis that have to take place on a daily basis in every NHS organisation to underpin such claims.

We do not believe this national exercise can be justified any longer. But without a considered and systematic process for reviewing and withdrawing unnecessary measures at a national level there seems little prospect of the FFT mandate ending soon. (Perhaps it will simply stagger on forever with no-one able or willing to finally kill it off?)

Performance management does not equal quality improvement

Secondly - and building on this point – one part of the FFT story is the dysfunctional outcomes that result when national policymakers and commissioners conflate performance measurement with quality improvement. The FFT doesn’t help NHS organisations to identify where to focus improvement effort. As another responder bemoaned, ‘FFT is burdensome and offers little in the way of insight … used in the NHS standard contract with a relentless focus on response rates, rather than what should be the case - doing something with the data we collect.’ Along similar lines another Director of Patient Experience in a large integrated Trust commented, ‘we made a critical mistake of paying attention to the wrong things: prioritising response rates over learning and that legacy remains. Too much work … is still tied up in feeding the beast, leaving exhausted staff with little time to focus on improvement’. The FFT has over time become a poor performance management measure posing as ‘quality improvement’. Both are necessary but when they are confused it is hard-pressed frontline staff who pay the price in terms of wasted time and effort.

Local solutions

Thirdly, despite the rhetoric about devolving decision-making closer to patients and front line services, the story betrays a lack of trust from the centre that local NHS organisations will do the right thing. The FFT was initially intended to provide comparable information, and is published on NHS Choices as a performance measure. However, NHS England now acknowledge that the FFT cannot be used to benchmark or compare between organisations; massive invitation and response biases render such an activity meaningless (and the national patient survey programme already fulfils this accountability and performance management function anyway). As one respondent commented, ‘non comparable (FFT) data prevents me from learning from other organisations and gaming prevents me from trusting the stats that are reported nationally’.

Without the justification of using the data in this way, why continue to impose a national mandate on every NHS trust in England? It seems the view of policymakers is that without the mandate poorly performing local NHS trusts simply would not gather and act upon feedback from their patients. In this vein, one responder - questioning whether the FFT is in fact the main impediment getting in the way of locally-based patient experience schemes and surveys (which he acknowledges as the highest value form of patient feedback) - compliments our ‘bravery’ in proposing an end to the mandate but suggests this as potentially foolhardy in practice. The fear is that attention to patient experience will wither away once the FFT is no longer enforced.

But what - beyond coercion to comply with national requirements - is the assumed mechanism by which collection of largely meaningless data helps either boards or frontline staff take patient feedback more seriously? The pleas from practitioners working with patient experience data in local organisations was clear: ‘give us freedom to listen [to our patients and families] without the constraints of a mandatory FFT’ and ‘give organisations the flexibility they need to target vital resources at local priorities that matter’. We agree. We think the majority of NHS organisations are ready to take on the task of listening and responding to the patients in ways that best suit their local context. In this regard the mandating of the FFT has outlived its usefulness. Earned autonomy should be the order of the day; other, more effective policy levers can be used to ensure local organisations are drawing effectively on patient feedback to improve the quality of their services.

Without anyone having the courage to kill the FFT off by ending the mandate, this ‘quality’ measure will continue to be a ‘zombie’ policy, stumbling on without any meaningful purpose, tying up limited local resources and engendering cynicism amongst staff. Regular review of measures is required, and as Berwick highlights, ‘intemperate measurement is as unwise and irresponsible as is intemperate health care.’

Jocelyn Cornwell is a trustee of the Nuffield Trust.

We are currently conducting a review of our indicators. If you have a view on which datasets we should (or shouldn’t) be monitoring, please get in touch.

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