Category: Ratings

Automated feedback texts

friends_and_family_testAn article on the Guardian’s ‘Comment is free’ website is attracting a lot of attention. Within two days of posting, it has been ‘shared’ on social media nearly 27,000 times and attracted 650 comments. The article is a first-person account of experiencing a miscarriage. The couple received excellent, sympathetic care, undermined somewhat by an automated text the next day asking, ‘How likely are you to recommend our A&E department to your friends and family if they needed similar care or treatment?’ The text presented a 5-point Lickert scale and asked respondents to text back 1 to 5 on the basis of how likely there were to recommend that A&E. This also happened with a follow-up scan at a different NHS site.

The couple felt the texts were ‘crass and inappropriate’. They did not want to be part of someone’s piechart being lauded at a meeting for improving ‘customer satisfaction’ (again the economic language that has proved so potently divisive given the debates about privitisation in the NHS). Instead it was the sincere, human interchange which this couple saw as their meaningful feedback: ‘We had thanked the excellent doctor who witnessed our anguished hope, who entered into that space with us at the start of a long night in A&E and held our hands when our nightmare became reality. I can’t speak highly enough of her … That’s the place for feedback: face to face, sincere thoughts and feelings expressed from one human to another.’ It seems the intimacy of the expression of gratitude was violated by the imposition of a faceless, administrative measure by text. But the comment, ‘I cannot speak highly enough of her’, is revealing. It suggests that language is unequal to the task of praise in this instance, thus the negative framing: ‘I cannot speak.’ That the article has been written at all is a way of expressing gratitude, even if it is by way of condemning the feedback system.

The measure, known as the Friends and Family Test (FFT) was announced by the Prime Minister in 2012 and is gradually being rolled out across all NHS services. Various healthcare trusts publish their results on their websites, and NHS England aggregates the results here. Defenders of it see it as a cost-effective way of improving services: the statistical measures are published so that some services are ‘named and shamed’ presumably so they will try harder. The feedback does allow for comments which is presumably what really delivers value in terms of suggestions for improvements or singles out particular individuals or practices for praise. Do these positive comments get fed back to staff? I hope so.

The framing of the ‘would you recommend?’ question is not appropriate for A&E. No one ‘recommends’ a trip to A&E: it should be a place of last resort. One can’t imagine googling the stats before deciding on the A&E at which to turn up, or instructing an ambulance driver to head for a distant A&E department that has a higher FFT score. So how could soliciting feedback be done better?

Presumably there is some admin involved in which phone numbers need to be transferred to the system which sends out the text. If there is joined-up thinking here, someone would make a judgement call about what method of soliciting feedback would be best, or whether it would be appropriate at all. Might this be open to corruption with Trusts cherry-picking patients to survey whom they think will give positive feedback? Perhaps, but an audited system in which decisions about whom to survey are transparent would be preferable to the one-size-fits-all approach. In this case, it would have been far kinder for someone to ring the couple to ask if there was any further support they needed, and gently asking an open-ended question about their experience of A&E. If the Lickert scale must be brought into play, framing it with an apology for the bureaucratic style might minimise the potential offensiveness. “I apologise for seeming to reduce your experience to a number, but the government requires us to collect this data. Could I ask you, on a scale of 1 to 5…?” And if the couple did single out individuals for praise, my first priority would be to let them know that that his/her efforts had been appreciated and it was fed into their staff feedback.

 

Gifts as commodities in the NHS?

I have been reading an influential essay by Arjun Appadurai, ‘Introduction: commodities and the politics of value’ from Appadurai, A. (ed.) (1986) The Social Life of Things: Commodities in Cultural Perspective. Cambridge: CUP, pp. 3–63.

Although focused on ‘commodities’ which implies an economic context that is missing (overly at least) from the NHS context, points in the essay have made me think about how one might frame a critical study of gratitude and the giving of gifts to healthcare professionals.

It is not customary to give gifts in the NHS (although this needs further research). Most anthropological studies of gift-giving are focused on the trajectory of gifts within relatively isolated, small-scale societies. Whilst a hospital environment, or a GP practice, could be viewed as analogous to a non-capitalist society (at least at the patient-facing end), gifts are meant to be ‘terminal’ (or ‘enclaved commodities’) rather than circulating. There may be very interesting things to say about how gifts are usually consumables or have a short shelf life. According to some studies (cited in this excellent article by Spence on patients bearing gifts), chocolates and wine are most often given. These are ‘luxury’ items that are relatively low priced and thus less potentially threatening to the professional/private boundary than more personal gifts.

Gifts given at Christmas are customary, and possibly more acceptable because they form part of rituals surrounding celebration and one need not be suspicious of ulterior motives on behalf of the giver. In an article for the RCGP’s The New Generalist publication in 2005 (quoted here), de Zulueta describes a range of reasons why patients give gifts, including:

  • to show genuine gratitude
  • to redress the balance in terms of power sharing
  • out of affection
  • to attract attention
  • to manipulate the practitioner to carry out preferential treatment or some other treatment they would not normally give
  • to expiate guilt for burdening the practitioner.

Anthropological studies are woefully inadequate when it comes to addressing motives for giving, yet assumptions made about motive is what drives policies about gift giving, including widespread advice not to accept any gifts at all. ‘Gifts’ also see to be treated as a homogeneous category regardless of the giver, so that gifts from patients are treated as if they are the same as gifts from pharmaceutical companies (which are unlikely to be stimulated by genuine gratitude – the most ‘sincere’ motivation for gift giving – and inevitably carry a whiff of moral taint).

My hunch is that the nature of gift giving in the NHS has changed in response to the way healthcare is organised. I predict that the rise of teams responsible for care has meant that fewer patients identify a single individual as being particularly worthy of gratitude. Gifts that can be shared are likely to continue to predominate (chocolates especially). I think (hope!) that a greater awareness of religious sensibilities of healthcare providers make a gift of wine a less popular choice (about 10,000 workers in the NHS are Muslim and eschew alcohol).

The role of patronage is important here too. Gifts from patients are often channelled though charities associated with hospitals or particular fund-raising initiatives. This separates the gift and any possibility of it contributing to individual gain. Initiatives like the ‘giving tree’ at the Brompton Hospital helps to bridge the gap between the impersonal cash contribution and the expression of gratitude to individuals or teams within the hospital.

A series of 'giving trees' at the Royal Brompton Hospital allow patients to express gratitude publicly whilst donating money to the hospital charity rather than an individual.
A series of ‘giving trees’ at the Royal Brompton Hospital allow patients to express gratitude publicly whilst donating money to the hospital charity rather than an individual.

Appadurai’s essay examines ‘instruments of value’ and reminds us that status participates in the economics of exchange. League tables, and specific ranking of individuals, could be seen as a rather insidious form of what Appadurai calls ‘tournaments of value’, involving status, rank, fame, reputation and ‘central tokens of value in the society in question’ (in the NHS, that could be analogous to ‘patient safety’): ‘Tournaments of value are complex period events that are removed in some culturally well-defined way from the routines of economic life. Participation in them is likely to be both a privilege of those in power and an instrument of status contest between them.’ The worrying aspect is that league tables treat people and skills as commodities, whose worth can be quantified by simplistic measures. In the context of concerns about the privatisation of the NHS, the use of league tables is held up as an example of transparency and accountability, and in the interests of patient choice (however illusory that may be), whereas the rhetoric of the hierarchy which is entrenched in the very notion of ranking reinforces the metanarrative of the NHS as a ‘market’ in which value is distilled into a set of indicators reminiscent of the trading floor.

Perhaps the most salient take-home message from Appadurai’s essay is that politics govern the contexts of value-based exchanges: ‘not all parties share the same interests in any specific regime of value.’ It is those interests that are woefully understudied.

Patients queue to thank GP Richard Hughes

Patients queued for hours to thank Dr Richard Hughes on his retirement. Image: The Mirror

This is a lovely story of how patients queued for hours to thank Dr Richard Hughes on his retirement. An ‘event’ such as retirement provides a focal point for gratitude – it seems a shame that many doctors receive a show of appreciation only at the end of their careers. One of the characteristics of the way we express gratitude, in Western societies at least, is that it often signifies the ‘closure’ of a particular transaction. (The word ‘transaction’ here seems freighted with economic meaning, rather unfortunately, but the rhetoric of gratitude is saturated with economic metaphors.) This closing shapes the framing of the act of gratitude as a ‘reward’ for past service: in terminis res, as it were, rather than in medias res.

Here is a round-up of news coverage of this story:

Daily Mail: The GP everyone in Britain wishes they had

Daily Mirror: Patients queue FOUR HOURS to thank GP retiring after 32 years serving community

Telegraph: Dr Richard Hughes: ‘I saw them through the best and worst times’ and A great family doctor is a treasure beyond price

The Times: Doctor’s prescription for a better health service

How frustrating must it be for the Hanway Medical Practice where Dr Hughes worked, to have received poor ratings (at time of writing) on the NHS Choices page for Ratings and reviews. Interestingly, in response to a complaint about difficulties in booking an emergency appointment, the practice manager invokes a comment received by the practice website:

The Practice regularly receives positive feedback from patients about the ability to get same day appointments and the helpfulness of staff; this is a written comment that was received via the Practice Website on the same day as the above comment ‘ Just wanted to express my thanks at the excellent service yet again from your staff. Have had to book 2 emergency appointments within the last week for my husband and your staff were friendly and helpful and my husband was seen both days by lunchtime’.

Gratitude is often expressed privately, but frustrated complainants are keen to use the public platforms provided by institutions further up the hierarchy (NHS Choices, rather than, or as well as, the practice’s ‘customer satisfaction survey’ on the website.

Take-home points:

  • Doctors often receive most appreciation when they retire.
  • Gratitude is more easily clustered around an ‘event’, whereas complaints are catered for at any time.
  • Although praise and criticism are both catered for under the banner of ‘feedback’ or ‘comments’, their rhetorical purposes are very different, and it is not surprising that public platforms are dominated by complaints.
  • Gratitude is more likely to be privately expressed at the closure of an encounter, whereas complainants want a more high-profile platform as a means to inducing change.