NPS Blog

Would you recommend your doctor to a friend?

The UK’s National Health Service (NHS) recently joined the list of public sector entities that are turning to the Net Promoter Score to gauge the loyalty of their various constituents when it started asking patients in England and Wales how likely they are to recommend the medical service they received to their friends or family.

UK Prime Minister David Cameron introduced the program, called The Friends and Family Test, last year. The effort aims to improve patient care by collecting feedback and encouraging providers to take immediate action to address problems, hallmarks of the Net Promoter System.

Last week, I discussed the origins of the Net Promoter Score (NPS) in light of the NHS program on iPM, a show on the BBC’s Radio 4. Tim Kelsey, NHS England’s National Director for Patients and Information, also explained his views of NPS on the segment:

“The Net Promoter Score has clearly, definitely in a very well-evidenced way been the core ingredient of turning round some very, very large businesses and some big public services overseas … We have all sorts of different ways of listening to patients, and one of those ways is listening through the hard statistical timbre of clinical data.”

The program is already off to a promising start. During the first three months of implementation this year, more than 400,000 NHS patients provided input about their experiences and the NHS made some of its initial findings public. Nevertheless, it is controversial because it is new and because some of the kinks may not have been worked out of the system yet.

Click here to listen to the segment. We’ve included a transcript, courtesy of CustomerGauge, below. The content is, of course, copyright of BBC Radio 4.

Net Promoter in NHS England, segment extract from BBC Radio 4 program “iPM” broadcast 21 September 2013

Host: Hello and welcome to IPM, the program that starts with its listeners. First, we have a story about the NHS and management consultants, but don’t turn off, it’s not what you think. It was reported this week that more hospitals in England are likely to be put in special measures, and the health secretary Jeremy Hunt says he has a rescue plan for failing trusts. He’s going to send in managers from top NHS hospitals to lend support. He said in the past, consultants had been favored, but they had only identified problems rather than solving them. Which is curious, in light of our NHS story today. It traces how an idea developed 10 years ago by a couple of American businessman ended up posted on the wall of an English hospital two months ago, being looked at by an A&E doctor who didn’t know what it meant. It’s a ratings number and a number that not only he needs to understand but you do too.

“Forget everything else” it said, this is the One number you Need to grow. It’s 2003 and businessman Fred Reichheld has just published a theory which is about to change the business world.

It will have a profound effect on companies you’ve heard of like Apple, Amazon, and BT. It’s called the Net Promoter Score, or NPS. And now it’s the basis of a new NHS measurement, the Friends and Family test. It rates your trip to hospital and results in the score of between minus 100 and a top score 100.

You’re going to see this number when you enter a hospital or visit your GP surgery. Currently, the test is only being used in England and Wales. But before we get to have the Net Promoter Score reach the NHS, back to those American business strategists who developed it.

Rob Markey: I’m fascinated by how really intelligent people can, on the one hand talk about how they value their customers and their relationships that they have with them, nd on the other hand, implement strategies and policies that are guaranteed to enrage them.

Host: That’s Rob Markey. He’s a senior consultant at U.S. management consultant firm, Bain & Company. He co-wrote the book “The Ultimate Question” with Fred Reichheld, who is something of guru in the world of management consulting. Back in the 90’s they were working with companies to develop loyalty strategies.

Rob Markey: We ran across Enterprise Rent-a-Car, where they had reduced their indicators of customer loyalty down to a single indicator based on a single question. And the leadership team there said “listen, you change your organization with clarity and simplicity”.

Host: So Fred and Rob set out to find the ultimate question that can be used in any industry.

Rob Markey: We tested, I don’t know, 12 or 18 different questions, and the one that was most frequently the best at predicting those things was ‘how likely would you be to recommend my product, my company, my service to a friend or a colleague or a family member?’ The essence of what makes Net Promoter powerful is buried in what Enterprise was doing with it. So it’s not actually the score itself, but it’s how they were using it. And that is, they were taking the feedback from individual customers and delivering it right away to the employees who needed to hear it.

Host: It has attracted a lot of criticism and subsequent studies claim that it is no better a measurement than many others. There is a whole story about how it has been adopted in the business world, but I don’t have time for that. I want to fast forward 10 years to its introduction in the NHS, but before I do I had a final question for Rob. Can you skew the results at all by only asking who you want to ask?

Rob Markey: Any—any—customer metric can be gamed. The key is to create a metric and a system that people in your organization view as beneficial to learn from. So that they believe deeply that learning can only be done when you get honest feedback from the right people. Oh, and by the way, I think you should institute measures to prevent gaming, especially in a situation where there’s going to be reporting and evaluation based on it.

Host: But why publish them if they are inaccurate if they very unhelpful for people?”

Tim Kelsey: But they aren’t inaccurate. Let’s look, we are launching a revolution (I might as well say it) in trying to support hospitals in this case to listen better to their patients. We want hospitals to be held to account by those who use them for the quality of their service. Even this doctor would agree it’s the right thing for us to be doing.

Host: And I played the response to our doctor. You get the idea of what I’ve done here.

Anonymous Doctor: I’m all for openness and transparency in the NHS. I don’t know anyone who works for the NHS that isn’t, that’s the only way to improve things. But I cannot see how a scheme like this is supposed to produce figures which will have any meaning or will be robust enough to be put to any good use. Essentially because it’s such a skewed sample that is being taken. One of my concerns is that just because a patient thinks that they have received good care, doesn’t mean say they have. Especially in a fast turnaround where I work in an emergency department. We might completely mistreat or misdiagnose somebody, but if we do it quickly and give them a cup of tea, we’re going to get a good score on the friends and family test. I don’t see how that can possibly be of any scientific use at all.

Host: Our doctor wanted to know the financial implications of the test. This is what Tim Kelsey says.

Tim Kelsey: We have put in a financial incentive so that money is not removed from the hospital for not doing this, but they get extra money if they get their response rate on a combined basis above 15% for both A&E and inpatient wards. But I think there are any 30 hospitals that in this country that didn’t therefore qualify for their incentive.

Host: And this is how our doctor responds.

Anonymous Doctor: I’m sorry, but that is essentially a fine for not meeting that target. Because if everyone that does meet it gets extra money, and those that don’t meet it don’t get extra, surely it’s the same thing isn’t it?

Host: And I put to Tim Kelsey, our doctor’s point about the figures possibly being skewed.

Tim Kelsey: There is no evidence at all that consultant clinicians go about making up their own death rates. And I have no evidence at all that nurses in hospitals are actually going about making up their friends and family test results.

Anonymous Doctor: I really think it is set up in such a way, or certainly in emergency departments, by which you cannot approach someone who has had a bad time and give them one of these cards. Not because you wouldn’t want them to give you a negative score, but because it would be an awkward situation and I just can’t see it happening. I don’t know any of my senior colleagues who approve of this scheme.

Host: I asked our doctor if he could see anything of value in the friends and family test.

Anonymous Doctor: Not in its current form, certainly. The idea of coming up with a number and a figure is probably what disturbs me most. And the data it is collecting is so soft, that I don’t think you can even compare one place with another using data like this.

Host: If you would like to find out more about the NHS friends and family test, there are full details on the NHS England website. And you can also see the Net Promoter Score for each Hospital on the NHS Choices website.


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