Harnessing patient feedback data: A challenge for policy and service improvement.

Online feedback from patients about their experiences of health services is increasing and likely to accelerate in the coming years.[1,2] In other sectors, such as retail and travel, gathering, interpreting and responding to both solicited and unsolicited online consumer feedback is routine practice and often seen as the key to success.[3] It has been proposed that consumer feedback can drive quality improvement, identify system failures, reduce patient harm and increase satisfaction with healthcare experiences.[4-6] However, we believe that health services have been slow to react to this phenomenon and few health organisations have found a way to engage with online comments. While recognising that online comments may present challenges for health services, we believe that such information could be utilised by healthcare providers, commissioners and policymakers to effect positive, cost-effective change in an NHS which aspires to put the patient at its heart.

Around 78% of the British population report using the internet, and 69%[7] use it to seek out general health information. The increasing amount of online feedback on healthcare includes comments on structured patient rating sites (such as PatientOpinion and iWantGreatCare) and also unstructured and unsolicited narratives about treatment, health services and illness in online settings such as blogs, fora and social media. Internet feedback forms part of the future vision of NHS England for a digital NHS service founded on the pillars of participation, transparency and transaction.[8] While historically, patient experienced data have often been seen as the “poor cousin”[9] in relation to other measures of hospital performance, the current NHS Operating Framework for England[10] describes patient experience as “the final arbiter in everything the NHS does” and demands that NHS organisations must elicit and respond to patient feedback including patient comments. This is especially relevant in light of the reviews by Francis, Keogh, and Berwick which have all noted failures within the English NHS to recognise and respond to feedback from patients.[11-13] The public value the opportunity to provide feedback, and to share the results, as shown in their response to the Friends and Family Test (FFT), which asks patients if they would recommend to their friends or family the facility in which they were treated.[14] The FFT received more than 10 million pieces of feedback in the English NHS in just over two years.[15]

Clearly there is a willingness to give online patient opinion a firm place within the health service, but this is complicated by several factors. Only a minority of users offer feedback about their healthcare experiences online, raising questions about the public awareness of online feedback in health, and representativeness and bias. German survey data indicate that less than 33% of patients are aware of rating websites[16] and an earlier study in 2012 found this was true for 15% of UK patients.[17] Factors that predict posting and using rating websites include health status, digital literacy, and a high level of trust in and perception of the usefulness of the information available online.[18] Ratings may over-represent the views of individuals from low income groups[19] and online raters are more likely to be younger, female and better educated.[17-19] Some online providers moderate and edit content, perhaps attempting to make it more palatable and acceptable to institutions,[20] but this may change the subtleties and nuances of the original comment. Little is known about what motivates those who choose to provide feedback, or about the effects this feedback has on other people who read it, including patients, and the health service staff and organisations to which it refers.

Currently, the landscape of online patient feedback is poorly understood. There is a need to understand the strengths, limitations and biases within these data. We need to learn from the experience of other sectors, and from the few examples of best practice which already exist within health care, such as the Birmingham Children’s Hospital Feedback app – the first of its type, it is free to use and comments are responded to by staff.[21] We also need to understand how to increase and encourage equitable participation in online feedback, perhaps specifically targeting groups that tend to be neglected because they find it hard to engage with current systems. Finally, we need to understand how data from online feedback can be best used by a healthcare organisation to take specific action to improve quality. This is a burgeoning area and warrants attention from all stakeholders, but few providers have found a way to realise its full potential and engage with patient comments – moving from simply listening to consciously reacting. We believe that health services could be well served by promoting to patients that they can and should review their experiences. Online feedback could be used to drive quality improvement, to improve patient safety and experience and to provide information to inform patient choice. The healthcare citizen of the twenty-first century should have the right (and perhaps, the responsibility) to comment on their care in a convenient and timely fashion, in the knowledge that their comments will be used to improve services.