The Irish Medical Times - NHS Pay for Play? Why Patient Satisfaction Could be a Risky Business
While in London recently I tuned into a radio debate concerning new plans for the NHS. Apparently, the famous health service is plagued with problems (aren’t we all - nods from the HSE). Top of the NHS troubles is a post-pandemic backlog, add that to the usual health funding challenges every government faces, and the ongoing staff shortages, which leads nicely on to public dissatisfaction.
The Labour run government wants to shake things up, the novel plans include tying hospital funding to patient satisfaction. It is part of a series of measures the government would like to introduce to cut waste and improve care. Cutting waste, will also include cutting waists as weight loss drugs will be used to tackle obesity. The anti-obesity medications are fodder for another day.
However, I was intrigued by the belt tightening suggestion that doctors and nurses pay could be influenced by a patient’s opinion. Under the proposal, a number of weeks after treatment, a patient could be contacted to give their opinion on whether the hospital deserved full payment, if the answer is no, up to 10% of the treatment cost could be diverted away from the hospital and towards a local ‘improvement fund’.
Even as a patient advocate I found this suggestion pretty radical. Money is a strong motivator and I could see how playing with the margins of somebody's pay packet could be a juicy carrot to wave them towards improvement. The NHS has conducted satisfaction surveys in the past but I don’t think they (or anyone else, anywhere else) has ever asked a patient to decide if the doctor should get full payment for services rendered.
Patients can feel somewhat powerless, we are a very vulnerable group, if we do experience what we deem to be bad care, it is hard to know how to feed this back. If we are surveyed for our thoughts, we don’t usually find out what happens next - Did anyone speak to the person who was rude to me, was the doctor told that I didn’t feel heard, are there consequences for half-assing their job, do they even care, is this going to happen all over again?
I can start to see how this radical suggestion has made its way onto the table.
But what exactly constitutes a bad performance and to what degree? How will subjectivity, grudges, prejudices, and a propensity to complain be sieved out from an objectively sub par service?
It's not evident what exactly will be measured. Are we talking; bedside manner, wait times, cleanliness, communication, pain management or will we be passing comments on peoples looks, tone and sense of humour (because that is what the rest of us are judged on)? Are we judging specific people or a team or the general hospital?
Behind it all is the word ‘satisfaction’ or lack thereof. In an ideal world health services would all be exemplary and held to the highest standard, with no mistakes and no unhappy customers. But unfortunately, we are all human, protocols fail, buses are late, corners are cut, feelings are hurt, accidents occur, mistakes and misunderstandings unfold. Of course, catastrophes happen too but I assume the aim of the survey is not to cover situations resulting in lawsuits, permanent damage or death, but more to assess the delivery of a routine standard of care.
Surveys tend to be completed by those with strong positive or negative feelings, it would be important to capture the silent majority. Perhaps, most of the people surveyed could be returning regular patients who are familiar with the staff and service and may have even experienced other hospitals and doctors. They could remain anonymous to allow for candour. It’s good to have the one-time user mixed in, but they should not make up the bulk. For those who are too sick or vulnerable, could a proxy give the feedback?
Under the plans, GPs will also be rated via the NHS app. I must admit, I will look at ratings if I am going to a restaurant or a hotel, but I’ve never felt the need to look at ratings for doctors or hospitals. No one vets the people who give these online reviews, they could be headbangers with vendettas, or if the write-up glows excessively, I assume it’s a relative or even a patient lost in the throes of Stockholm Syndrome.
I am part of that transitional generation who grew up in a system that assigned you a doctor. For those of us who now mix and match with private care we tend to go with relatives, friends or GPs recommendations, based on their own personal experience of the doctor. We don’t look to see what a stranger online said. Rising generations are a different kettle of fish, they review every cab driver, who in turn reviews them back. This accountability policing is admirable but surely not immune from popularizing, subterfuge, and intolerance.
With satisfaction surveys there is the risk staff could start prioritizing aspects of care that are easily measurable by satisfaction surveys (e.g., friendliness) over clinically vital but less satisfaction-generating aspects (e.g., delivering difficult news, adhering to strict protocols).
Direct financial penalties could create a demoralizing culture of blame leading to a stressed and defensive workforce - that’s assuming they stick around. An unscrupulous person could try to game the system, stacking their deck with ‘easy’ patients, avoiding difficult conversations, ensuring they receive 5 star reviews. In this environment, would a hospital even want to take on a complex case requiring long difficult treatment that usually doesn’t spark feelings of satisfaction?
Even assuming everyone's scruples are impeccable, we all have different baselines of satisfaction. In a disadvantaged or indeed advantaged area perceptions could be skewed on what defines objectively good care thus describing it otherwise.
There are other strong motivators aside from money such as saving face. What if the same survey was conducted but instead of it resulting in a pay cut, it would be published for all to see. Or is that an even more barbaric display of public shaming?
Instead of threatening to cut, the NHS could flip the paradigm and promise a bonus for those who satisfy the public. Pride is a powerful motivator, I know I’m a happier person when I feel rewarded and valued. I tend not to find penalties helpful, usually creates more of a I-want-to-leave-my-job vibe.
What if the table gets turned and the doctors start reviewing the patients, like an Uber type app with two way rating. The doctors might have a thing or two to note about patient punctuality, attitude, attention, adherence to medication, civility and so on.
Perhaps in the survey the patients could be asked for recommendations themselves on how to correct the problems they faced, including the option of less pay for those involved. I think it could be interesting to see how many patients actually want that. Another approach could be to delay a bonus until improvements were demonstrated and shared with the patient (as opposed to cutting pay, no backsies).
Sometimes a personal apology or an explanation could change a person’s heart. I have had many bad care experiences in a variety of hospitals and it never occurred to me to dock someone’s pay. Drag them over some lightly burning coals maybe, a public apology on the evening news, or a personal heartfelt reassurance that they had changed via a hospital wide live-streaming would be my simple request.
The UK government seems determined to use the threat of personal financial loss as a way to improve the NHS. The potential plans include a reference to the NHS Hospitals Chiefs not getting their bonus if they fail to cut their hospitals waiting times.
You would assume extensive research has gone into the reason for long waiting times before the suggestion of dramatic top down cuts, but I have learned never to assume. Is it possible the waits are so long because the staff are trying to achieve a level of service that meets the patients satisfaction. It isn’t obvious to me how to cut the waiting lists without compromising the service. Have they thought about cutting the administrative bloat - maybe they could use some of those weight loss drugs they are so fond of.
I am sure the NHS, and every health service in the world, has wastage and ill suited staff taking up hospital space and time. We probably do need new methods to weed them out, I’m just not convinced that using a patient survey as the hatchet tool (certainly only after one treatment experience) is the way to go.
Is the real problem less about what the NHS staff is doing and more about what they are missing e.g. beds, equipment, processes and staff. I’m not convinced a patient survey will address these systemic issues.
I strongly believe patients should have their say, so I am in favour of surveys. I’m not hugely in favour of punitive measures to achieve growth (although my daughter who recently had her iPad confiscated may disagree). Instead of just involving the patient in a survey, how about also educating patients on their rights, what good care looks like, and how they can raise their concerns in an effective way. To protect everyone it may be of benefit if the patient's voice could resonate alongside a peer review or internal audit to give a more insightful picture of what/who went wrong with the service the hospital provided and why.
I’m all for change and trying something new, I just hope that in the UK government’s bid for the NHS to cut waste, it doesn’t merely cut corners.
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