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How much notice is taken of the perceptions of patients and the public in evaluating the performance of the NHS?

Illustration of a man wrapped in bandages at a fruit machineAsking patients for feedback about their care is a great way to assess NHS outputs

How much notice is taken of the perceptions of patients and the public in evaluating the performance of the NHS?

We have, for so long, heard about patient-led or patient-centred services, one might easily assume that public perceptions are a vital element in assessing the success of health services. Indeed, substantial energy and resources are invested by Trusts and healthcare providers in regularly surveying patients' satisfaction with, or experience of, the healthcare that they have received.

In this way, we learn a great deal about the extent to which patients experience delays in obtaining services, poor explanations for their health problems and impersonal or discourteous care from providers.

However useful such evidence is in monitoring services, surveys of patient NHS experiences ultimately address the 'packaging' of healthcare. They do not address patient views about the core product - improvements to health.

Of course, if the packaging is unattractive, for example if a patient waits a long time in a grey and depressingly furnished clinic only to receive minimal and impersonally delivered explanations about their health problems, this is both inherently undesirable and may reduce the extent to which the patient feels the benefits.

Usually, however, the external packaging and core content of healthcare need to be considered quite separately, whether by a patient or by those responsible formally for monitoring healthcare quality, such as the Healthcare Commission.

input vs output
The Atkinson review of government output and productivity was published in 2005. It criticises the widespread assumption that in public services, such as health and education, inputs can be equated to outputs; the view that, for example, the productivity of Primary Care might be assessed by estimating numbers of GPs in the service, or numbers of consultations.

The review castigated government statistics for being far more reliable and informative on inputs than outputs.

Anxieties about NHS inability to assess productivity will grow within the Treasury now the health service is in its seventh year of unprecedented growth in funding and given growing public unease about progress resulting from such largesse.

The Treasury should pay particular attention to the section of the Atkinson report that discusses potential solutions to the current lack of evidence about outputs. Atkinson was particularly impressed by evidence, from York University and others, that measures of health gain are available and offer a potential method for measuring changes in health produced by the NHS.

The private provider BUPA has been using these measures for some time to monitor health outcomes. The measures referred to by Atkinson are essentially reports by the patient about their health which, if used repeatedly over time, can track outputs of services.

nhs questionnaires
It will not surprise readers in pharma to hear that a solution to the problems of measuring NHS outputs is a channel that has been used for some time in industry - questionnaires in which respondents assess their health in various domains.

They have an established role in assessing costs and benefits of new drugs. In the last 20 years, hundreds of questionnaires have been developed to get respondents to report relevant aspects of their health in a standard fashion. Extensive effort and resources, in some cases significant sums, are invested in development work to ensure that the answers will be accurate and reliable.

Two broad types of questionnaire are available: disease-specific instruments are intended for respondents with a specific health problem, such as arthritis or migraine; generic instruments are intended to be applicable across the widest range of problems.

They have a wide range of potential uses beyond pharmaco-economic studies. They can be used to assess the health of the population, the needs of those attending particular clinics, and used in clinical trials or quality assurance audits of effectiveness. Questionnaires can play a key role in improving communication and collaboration in individual patient care. However, they are not as widely used in the NHS as their enthusiasts urge.

Low uptake
Many reasons have been suggested as to why patients are not more commonly invited to report their health through questionnaires in the NHS. Least likely is that the instruments produce unreliable answers; all of the evidence suggests that the answers to health status questionnaires produce evidence that is as reliable as most clinical measures.

It might be that questionnaires in clinics are clunky and disruptive to routines. The use of touch-screen technology overcomes that problem. There may be fears that they would not be acceptable to patients. Yet, evidence suggests that patients welcome reporting their health in this way. Maybe health professionals themselves are not enthusiastic. Not quite: GPs, for example, say that they want to learn more about their patients' perceptions of health problems.

It has been said that it is difficult to interpret changes over time observed through patient-reported outcomes. Yet, the Department of Health supports efforts to make patient-reported health instruments more widely understood (http://phi.uhce.ox.ac.uk).

The most likely explanation for poor uptake is culture and tradition. We are still not used to techniques that give the patient such a central role in providing information about health and ultimately about NHS outputs. We prefer traditional, professionally-determined concepts and measures.

In one area, these cultural barriers are beginning to break down. It is recognised that to address the massive challenges of managing chronic illness, the patient will have to be an equal partner to the health professional and health service in identifying solutions that maintain quality of life in the community and reduce the need for expensive use of acute care.

NHS R&D
January 2006 saw the launch of the government's strategy for R&D in the NHS, Best Research for Best Health. It represents a very ambitious and strategic approach to what has seemed a Cinderella part of the NHS. Patient- and public-partnership is a key mantra in the document, reflecting the reality that clinical research can only happen through public consent and support. What better way to sustain patient involvement and commitment to R&D, as part of the NHS, than to place the experience of patients at the centre of assessing outcomes.

Like all potentially great ideas, an excess of enthusiasm might be followed by disenchantment if patient-reported health questionnaires became the fashion and practice of all Trusts over night. More realistic, and probably more constructive in the long run, would be to test the role of patient-reported health in monitoring outcomes in some promising pilot sites.

The Author
Ray Fitzpatrick is Professor of Public Health and Primary Care, University of Oxford

2nd September 2008

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