Viewpoint: Friends and family test for primary care - driving up standards or bulking out bureaucracy?

From April A&E and overnight inpatients will be asked whether they would recommend the services they received to their friends and family, writes Toby Knightley-Day

Mr Knightley-Day: 'Engaging with the initiative will be beneficial to all GPs.'
Mr Knightley-Day: 'Engaging with the initiative will be beneficial to all GPs.'

This seemingly simple friends and family test (FFT), to be rolled out to GP practices as soon as possible, has already sparked considerable debate. It was launched to a chorus of support for patient empowerment, allowing service users to dictate the standards of their health service; for others, its apparent limitations – particularly its ability to inform change at the frontline – suggest it will be no more able to prevent large-scale failures than existing tools.

With such strong feelings aired publicly, it could be regarded as surprising that the government has committed to the introduction of the FFT into a sector in which it is untested – primary care. Nonetheless, there are powerful arguments driving its cause.

Introduction to primary care

In a speech at the end of January, health secretary Jeremy Hunt announced that the care failures that took place at Mid Staffordshire Foundation Trust would not have happened if patients had been consulted and listened to.

The Francis report reinforced this, highlighting the weakness of patient voice in the system. Before touching on the specifics of the role the FFT might play in primary care, however, it is worth outlining why its efficacy has already been questioned.

Most criticism has focused on the score element of the test. A comparable score will allow the centre to measure system performance, but, in the past, such measures have been target-driven and managerial, and rarely fed into frontline improvements. It’s worth noting, then, that in its original form, the FFT was a score linked to a text justification for that score – a system that allows feedback to link directly to an event.

The trouble is, the government’s guidelines have allowed trusts the option of dropping this qualitative element, potentially leaving them with just a headline score. If a similar decision is made in primary care, there is the potential for this score to become little more than a qualification for initiatives such as the quality premium; rewarding those that perform well, but not assisting those who need to improve.

Full friends and family test

Consequently, those commissioning and overseeing the service need to understand how the FFT should be implemented, why the ‘full’ version – including free text – is essential, and how embracing the measure will be good for patients and service providers alike.

Admittedly, this background is unlikely to inspire confidence among those working in primary care – it looks like a top-down management tool for those already overworked, standing between them and their main concern: their patients. Nonetheless, there is a place for the FFT – or a similar measure – in this sector; one that should not be sold on the promise of quality premium payments, earned liberties or other schemes alone.

From April, reforms will change the health and care landscape. Clinically-led commissioners will take on the majority of commissioning decisions and will be accountable for them and the quality of care that results. As we move towards a patient-centred, integrated health and care system, we need data to help us shape these services. Of course the FFT is not a panacea for all the health and care sector’s challenges, but it could deliver improvements on two fronts.

Deliver improvements

Firstly, within primary care, the feedback would provide insight into the quality of services offered by providers; text feedback – identifying strengths and weaknesses from the patient perspective – could then empower providers to shape and deliver the services their patients expect.

Secondly, if FFT data feeds into the commissioning process, CCGs and commissioning support units should have a common set of current patient experience data. This will allow them to monitor service quality as well as smooth and refine care pathways. Given that the Francis report also suggested GPs take on a ‘monitoring role’ to ensure hospitals are providing good quality care, this data is likely to be very valuable.

As primary care is the gateway to the NHS, It is not entirely surprising that such an initiative should be introduced. Although existing surveys feed into service development and policy, none are used universally or connect individual experience with point of service in a way that encourages behavioural or cultural change; if we let it, the FFT can bridge this gap across the whole NHS.

It’s because GPs play such an invaluable role in practically all care pathways that their engagement is so important to the initiative’s success. If they embrace the measure – starting by encouraging their patients to feedback about providers – then GPs will have the power to influence those providers, ensuring their patients enjoy the best quality care, as defined by themselves. As the FFT for hospital services has already been included among the metrics for the CCG quality premium, and all indicators suggest primary care services will soon be included, engaging with the initiative will be beneficial to all GPs.

* Mr Knightley-Day is a managing director of Fr3dom Health, a provider of the friends and family test as part of wider patient and public involvement strategies.

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