Hospital Trusts! You Need to Get the Friends and Family Test Right. And it Takes Effort.

From April 2013 providers of NHS funded acute services for inpatients and patients discharged from A&E will need to ask patients if, generally speaking, they would recommend the service to their friends and family.  Replies will vary from being extremely likely to do so, to being extremely unlikely to do so and there will be some follow-up questions to enable Trusts to dig deeper into the patient experience.

Now this kind of data is often used to calculate the net referral rate (NRR).  And this  has been around for a long time (i.e. the [% extremely likely to recommend PLUS the % likely to recommend] MINUS [% extremely unlikely to recommend PLUS % unlikely to recommend]).  The measure has its fans and it has its detractors, perhaps worryingly  it has been used by many of the UK’s leading retailers for decades.  But whether you like it or not  this approach is something rather new for the NHS.

The results of the Friends and Family Test will certainly allow for some real time comparisons of  service quality across hospitals in England.  There will be no reason why all qualifying trusts can’t be ranked 24/7 by their NRR – perhaps there will be a neon sign above every hospital in England displaying its NRR, in real time?  Why not? There will certainly be no place to hide, because actually this is a very transparent measure of service quality.

But there are some real issues in implementing the Test that Trusts need to consider urgently, especially because overall the guidance is a tad thin on methodology and this detail matters a lot.  Indeed Trusts that take a light-hearted approach to the Friends and Family Test are likely to do themselves some avoidable damage.  Generally speaking, this is because the more you casually rely on people to come forward to rate their experience the more likely you will be to hear from certain types of patients; most definitely those who are not happy and the less likely you will be to capture a sample of the true patient experience.  So the way the test is presented, in the guidance, is full of design issues that Trusts need to think about and take a decision on now.

  1. No preferred method! Don’t be fooled by this. The more you rely on people going out of their way to rate their experience the more likely it is that your results will be unrepresentative.  Take proactive steps to make sure all patients are encouraged to rate their experience.  Your staff will need to be involved in making this happen. And this can’t be done in a way that will bias your responses. So you can’t ask staff to hunt out happy faces and get them to complete the survey, for example
  2. Response rates matter! The 15% response rate is a red herring.  Aim high. A 15% response rate may not be representative of patient experience unless you are very lucky.  Aim high and maximise your response rate.  If you rely on a 15% response rate it could be 80% bad news.  Remember this is not a complaints form.  It is a patient satisfaction survey; design and execution is massively important
  3. Many people are hard to reach! Hearing from hard to reach groups does not happen without effort.  Most of the patient population is hard to reach when it comes to surveys like this: ask yourself how likely you are to complete a customer satisfaction survey, or your friends, or your family?  An array of feedback methods is important and you will need to be proactive in encouraging people to respond. The Test will not work well without imagination and a desire to hear what people think. Barriers to participation are important as are incentives to take part
  4. Achieving a high response rate is something to be proud of.  Not only may it make your results more representative, but is also shows that your Trust is serious about capturing the patient experience.  Head for number one spot and max-out your response rate
  5. This is not about research perfection.  The guidance does not seem to favour a well structured (and expensive) survey methodology (like a random probability sample, which incidentally could provide the most accurate measure of reality).  Rather the point of the test seems to be more about timely, responsive and real-time feedback. This means volume and response rates matter: the more the merrier.  Get people to rate their experience come what may!

So getting the Friends and Family Test right will take a lot of effort.  It will involve culture change, a well thought through methodology, the use of technology and effective publicity. There are also lots of experts out there who can help, including Participate ( of course, as it is unlikely that this can all be done in-house.  There are some real issues about Trusts collecting and reporting their own performance for example.  For scores like this, independence often matters.

Participate is here to help with measuring and understanding patient and public experiences and people’s aspirations for the NHS. If you need help please contact


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s