One of the highlights and first deliverables of the data-driven revolution in the NHS is the five star ratings and feedback system at NHS Choices, which allows patients to rate their experiences with GPs surgeries.
In theory it should allow everyone to make informed choices about the care they receive and who they receive it from.
However, there are some serious caveats, and not the ones we might automatically raise. The traditional objection to the choice agenda is that when you’re lying at the side of the road, you’re neither in any fit state to pick a hospital, and nor should it matter: one would hope that any hospital will be capable of giving you adequate care. But GPs’ surgeries are different: primary care is more planned, and your patronage can affect a surgery’s earnings, which ought to incentivise quality.
Furthermore, the fact that most surgeries are desperately short of available appointment times and are forced to offer a bizarre (and widely differing) range of booking schemes for urgent care which make seeing a doctor quickly akin to a black art also doesn’t actually affect the ratings system – because it’s a universal challenge. It’s annoying, it’s counterintuitive, it doesn’t help the pressure on A&E, but it doesn’t affect the ratings benchmark.
No, the elephant in the room for ratings is that we, the patients, generally don’t have any medical qualifications. We are extremely ill placed to judge the quality of the care that we receive in a meaningful way. By far the most important person in a primary care setting is… the hard-pressed (and therefore often grumpy) receptionist.
For a straw-man assessment of this assertion, we have examined all the feedback from the five medical practices offered by NHS Choices within a one mile radius of Nick’s London home over the past year. Sure, it’s not an exhaustive survey, but illuminating nonetheless.
The following chart shows a combined qualitative assessment of these surgeries across all discernible criteria mentioned by patients. In other words, we have not made any criteria up – if it was mentioned by a patient, it was included.
The chart also does not differentiate positive from negative – where patients mention that appointment booking was easy (and sometimes they do), that is as much a notch on the chart as where a patient has grouched about lack of booking availability.
First off, note that the friendliness and administrative quality of nurses, receptionists and support staff (this includes a warm welcome and admin functions such as ensuring that prescriptions and bookings are correct) is way out in front as a patient feedback motivator.
Second, note that you have to go an awful long way down the list (care / prescribing quality from the GP and feedback of specific medical insight, at 7 and 5 items apiece) to see medically important commentary. Medical issues amount to around 8% of overall feedback.
There’s another issue, too. The majority of medical issues take time to resolve. Some are never resolved. Conversely, our natural predisposition towards criticism in the heat of the moment along with the simplicity of the modern click-to-feedback mechanism which allows us to do so, means that the feedback loop subtly promotes short-termist feedback. It invites us to assess what happened today, not overall; and from an experiential viewpoint, not one of assessed outcomes.
Again, it is not our intention to belittle the patient, nor to denigrate the undoubted value of ‘bedside manner’. Our analysis is also imperfect – we’re sure Steve Dubner and Ben Goldacre would hang our amateur assessment out to dry (for starters, what counts as specific medical insight rather than just good bedside manner is entirely our own decision).
We’re not even deriding the value of ratings and feedback – it’s a welcome and refreshing real-time advance. In particular it is helpful for patients to see conflicting views on a single parameter (for example comparing positive and negative comments about doctors’ attitudes) and nothing short of beautiful when a respondent comments directly to counter a previous comment.
But healthcare isn’t eBay. The Care Quality Commission is rolling out five star ratings systems for all sorts of healthcare contexts in the coming years (care homes, for example), and it is incumbent upon patients to realise that in any structure, it is possible to game the system and divert the patient’s attention.
Patients should remember that as we know only too well, a doctor can be a jolly nice person and turn out to be a serial killer.
And practice owners and managers should remember that, at least for now, the receptionist is the most important employee by a mile.