Written evidence from Picker Institute
Europe (REV 14)|
Picker Institute Europe is a not-for-profit organisation
that makes patients' views count in healthcare. We:
- build and use evidence to champion the best possible
- work with patients, professionals and policy
makers to strive continuously for the highest standards of patient
1. Picker Institute Europe developed the methodology
of measuring patient experience in the UK. It has carried out
numerous national patient surveys for the national survey programme
and is now the single co-ordinating centre for these surveys under
the Care Quality Commission. It also provides patient feedback
to over 100 NHS trusts every year, using a variety of methods
including "near real time" feedback.
2. Picker Institute Europe has worked over several
years on the development of medical revalidation. It was a member
of the Chief Medical Officer's high level group, leading to the
White Paper, "Trust, assurance and safety: the regulation
of health professionals"; and of his working group on
medical revalidation, which produced the 2008 report: "Medical
revalidation - principles and next steps". This document
affirmed that patient feedback would form part of the evidence
base for appraisal and revalidation.
3. Revalidation was developed in the interests
of patients, but that focus keeps being obscured. The Select Committee
on Health's Inquiry is a timely opportunity to help the medical
profession regain that focus.
4. In this submission, Picker Institute Europe
wishes to highlight the following points, from the perspective
of an organisation focusing on patient-centred healthcare - and
the role, within it, of direct feedback from patients.
- No further delays.
The pace of implementation of revalidation has been too slow.
Under current proposals, regions that have not prepared for revalidation
may be allowed further, unacceptable delays. We propose that all
regions should be ready to introduce revalidation by a deadline
of 18 months after the early adopters begin.
- Full integration and regular use of patient
feedback. As agreed by the CMO's working
group, the purpose of revalidation is not just to identify unsafe
doctors, but to create continuous improvements in quality. Direct
patient feedback on doctors' performance can help assess core
standards and is an essential tool for quality improvement. Patient
feedback should be fully and properly integrated into medical
appraisal at regular intervals, at least annually and achieving
a representative sample of patients sufficiently large to ensure
- Now is the key time to review and clarify
the role of patient feedback. The medical
profession remains unclear and unfocused with regard to the role
and value of patient feedback within appraisal and revalidation.
The current hiatus presents an important opportunity to re-open
discussion, with the involvement of relevant patient-focused organisations.
We would respectfully request the select committee to recommend
this opportunity must not be missed.
5. Picker Institute Europe wishes to comment
on two issues within the Inquiry: the way in which the GMC proposes
to establish revalidation, and the responses to the consultation
and the GMC and UK health departments' statement of intent issued
on 18 October. We will cover these issues together.
6. Our concern throughout is that revalidation
should be implemented in the foreseeable future, with the experiences
of doctors' patients fully and effectively integrated into their
appraisal and revalidation, in such a way as to assist continual
improvements in quality.
7. Patients expect their doctors to be fit to
practice, to be effectively regulated, and to be monitored for
their competence. Most patients assume that regular monitoring
does take place. Medical revalidation was developed in response
to high level concern that adequate checks were not in place,
and that this posed risks to patient safety and was not conducive
to achieving high quality care.
8. Revalidation, and associated appraisals, depend
upon the regular gathering of good quality information about doctors'
performance. At the launch of the White Paper, "Trust,
assurance and safety", in 2007, the then minister for
health and the Chief Medical Officer confirmed that this information
would include direct feedback from the doctor's patients. Subsequently,
in 2008 the CMO published "Medical revalidation - principles
and next steps" which formally included patient feedback
within the proposals for "multi-source feedback" which
all doctors would need to collect.
9. Methods of collecting patient feedback - measuring
patient experience - have been available in England since at least
1998, when Picker Institute Europe conducted the first national
patient survey (of primary care) for the Department of Health.
Many of the "core questions" in the national patient
surveys can be used, or adapted for use, in assessing the performance
of individual health professionals. There are also many instruments
developed by academic researchers, designed specifically to assess
the quality of individual consultations with patients. For example,
a recent review by Picker Institute Europe for the King's Fund
identified 15 relevant questionnaires designed to study patient
engagement in primary care alone.
10. Since at least 2008, various parties have
been developing patient questionnaires for the purpose of revalidation.
The General Medical Council has developed its own questionnaire;
the Royal College of GPs has approved at least three other instruments.
11. Hence there is no shortage of well developed,
tested and validated questionnaires and indicators which can
be used, or further adapted, to provide doctors with their patient
12. Patients cannot be expected to report on
the clinical competence of their doctors. However, they can report
aspects of their own experience in consulting doctors, which are
relevant indicators of the quality of the care being provided.
13. For example, communication skills are key
to correct diagnosis, understanding patients' symptoms, choosing
the appropriate treatment option, and co-ordinating the patient's
care with others.
14. Patient experience questionnaires would typically
include questions about these communication aspects. Those used
in national surveys include:
- Did the doctor listen carefully to what you had
- How much information about your condition or
treatment was given to you?
- When you had important questions to ask a doctor,
did you get answers that you could understand?
- Did the doctor treat you with respect and dignity?
15. A key question used consistently in the national
surveys is about the level of involvement the patient had in any
- Were you involved as much as you wanted to be
in decisions about your care and treatment?
16. These questions are based on what patients
say is most important to them. They are directly relevant to the
duties and required competencies of doctors: Good Medical Practice
(2006) contains a duty for all doctors to work in partnership
with their patients, including involving them in decisions. GMC
guidance has further elaborated this duty, by advising doctors
that consent to treatment must be sought in the context of shared
decision making with the patient;
and by requiring all undergraduate doctors to demonstrate these
competencies in order to qualify.
17. Patient experience is recognised as central
to healthcare quality. The NHS Next Stage Review
defined quality as three components - safety, effectiveness and
patient experience - and this formulation has been explicitly
accepted by the coalition government.
18. This recognition is driven by increasing
evidence that the success of healthcare depends significantly
on the extent to which patients are engaged in it. Evidence
from 280 high level and systematic research reviews, synthesised
for the Department of Health by Picker Institute Europe, shows
that engaged patients are, for example, more likely to choose
appropriate treatment, less likely to choose highly interventionist
options, more likely to adhere to chosen treatment (such as a
course of medication), more confident to cope with their condition
and its impact on their lives, and more likely to adopt preventive
approaches such as attending appropriate screening.
19. Direct patient feedback, then, is both
achievable and highly relevant to care quality and to the assessment
of doctors' competence to carry out their duties.
Doctors' uncertainty about patient feedback
20. Over the
last four years it has become clear that many doctors are uncertain
and fearful about the collection and use of direct patient feedback.
For example, only 67% of respondents to the GMC's 2010 consultation
supported the involvement of patients in feeding back through
questionnaires - even though Department of Health and GMC policy
is unambiguous about this requirement.
21. Likewise, in a recent survey of GPs by the
King's Fund, 57% of respondents thought that patient surveys were
the least effective approach to quality improvement.
22. This is in part understandable. Responses
to the consultation also showed a clear preference for basing
appraisal on information that is already routinely collected;
but patient experience is not yet routinely measured at the level
of individual doctors, and doctors are unfamiliar with its evidence
base, methods and significance.
23. However, it may also be in part due to medical
prejudices. Research studies and programmes relating to patient-centred
healthcare have concluded that many doctors are resistant to concepts
and language of patient-centred healthcare.
Patient feedback is sometimes regarded as irrelevant, or wrongly
perceived as being about patients "rating" their doctor.
The communication, partnership and shared decision-making that
are required by Good Medical Practice are often derided as "fluffy
stuff", "touchy-feely", or things that nurses can
do but doctors don't need to worry about.
24. It is however important to note the increasing
recognition and acceptance of patient feedback as a valid and
important measure of the quality of care within national professional
organisations and associations. The Society for Cardiothoracic
Surgery for example, a pioneer of transparency in the publication
of performance data, is currently developing its own patient experience
measurement tools with a view to publishing patient experience
data alongside data about the clinical outcomes achieved by individual
Lack of clarity on the role and use of patient
25. For the above reasons, the role of direct
patient feedback in appraisal and revalidation has often been
misunderstood and downplayed in the development of plans for revalidation.
26. In its consultation document, the GMC characterised
patient and public involvement as a way of inspiring confidence
in the way that revalidation will work. Picker Institute Europe
emphatically disagreed, arguing that:
"The patient experience is a core dimension
of "quality" in health and should be positioned as a
core dimension of doctors' competence and performance. We do not
see this reflected in the GMC's approach."
27. In its response to the consultation (which
quotes the above passage), the GMC makes the robust statement
that "Patient and public involvement is expected, and will
be included in revalidation". It recognises patient feedback
as an important "developmental tool" for doctors. However,
it also continues to position patient and public involvement as
"critical to ensuring confidence in revalidation".
28. The point remains that in the face of doctors'
fears and uncertainty, the way the GMC positions patient and public
involvement, and patient feedback, is critically important. It
should give an unequivocal lead to the medical profession
- in line with the duties it promotes in Good Medical Practice
- that the patient experience, as reported by patients, is a core
part of the quality of doctors' performance and requires regular
monitoring and, where necessary, remedial attention.
29. In response to concerns expressed by various
respondents to its consultation - that patient feedback questionnaires
may not be "robust" or reliable, or may be too onerous
to administer - the GMC proposes further review work, to assure
itself and others about the nature of the surveys.
30. We consider this unnecessary - this is already
a well researched area. Royal Medical Colleges have moved beyond
this position, to examine and approve specific questionnaires.
We would urge the GMC to involve recognised academics with expertise
in patient experience measurement from an early stage, and to
conclude the review as rapidly as possible.
31. More generally, we remain concerned that,
even at this late stage in the development of revalidation, the
role and use of patient feedback remains at best unclear, and
at worst, disputed and undermined. The current hiatus, while piloting
is established and conducted, offers a very important additional
opportunity to clarify these matters.
32. We therefore respectfully request the
select committee to recommend that the opportunity should now
be taken to initiate a further debate and discussion aimed at
clarifying the role of patient feedback within appraisal and revalidation.
This should be a balanced debate, involving patient-focused organisations
and the medical profession as widely as possible.
Frequency, consistency and significance of patient
33. Our concern remains that, in the planned
approach, which is the responsibility not only of the GMC but
also of other bodies including the Department of Health, patient
feedback will be collected and used:
- with less commitment and recognition than other
types of information;
- infrequently; and
34. In its consultation document, the GMC described
patient feedback as "useful supporting information",
reinforcing the view of many doctors that such information is
marginal. In its response to the consultation the GMC revises
this to: "one of a range of types of supporting information
that doctors will collect to demonstrate their practice at appraisal".
This at least gives more of an appearance of equality with other
35. We reiterate our contention that patient
experience information is capable of being used to assess core
elements of the quality of doctors' care-giving. These include
mandatory aspects of the "patient partnership" duty
in Good Medical Practice, such as:
- listening to the patient;
- explaining the patient's condition;
- giving information about all treatment options,
including that of doing nothing, and their associated risks;
- answering questions in a way that the patient
- supporting the patient to care for himself and
to adopt appropriate behaviours;
- involving the patient (to the extent that they
wish) in discussions and decisions about their health and healthcare
- (and achieving consent to any treatment in this context).
36. We also reiterate that the evidence shows
that where these competencies are absent from consultations, care
and treatment will be less effective as well as being a poorer
experience for the patient.
37. It is incumbent on the GMC to defend and
promote its standards, and to exercise leadership in this field.
38. The risk here is that doctors, their supervisors
and clinical peers, and responsible officers, may underestimate
the significance of any patient feedback that is collected, and
therefore may not act upon it. They may believe it relates only
to "people skills", not to core best practice.
39. This would be unfortunate, since, as the
GMC notes, patient feedback is an important developmental tool
for reflective practice. In Picker Institute Europe's experience,
regular assessment of the patient experience, with attention to
trends over time, is a particularly useful quality improvement
tool when used by those who are committed to acting on
its results. It is a sensitive measure of whether changes that
are designed to improve quality are having an effect where it
matters most - in their effect on patients.
40. However, to be used effectively for quality
improvement, patient feedback should be gathered frequently enough
to be able to give a picture of performance over time, including
the impact of any changes that doctors have made to their practice
as a result of previous data.
41. In this respect the current proposal - that
patient feedback might be gathered only once every five years
- is wholly inadequate and places a question mark over the utility
of collecting it at all.
42. There is a clear contradiction between the
GMC's statement that patient feedback is "is one of a range
of types of supporting information that doctors will collect to
demonstrate their practice at appraisal" -- and its proposal
that the feedback will not be gathered annually for appraisals.
43. We believe that patient feedback should be
gathered at least annually, to be used in each appraisal. Annual
collection of feedback is not onerous. "Medical Revalidation:
principles and next steps" noted in 2008 that "Many
trusts already ensure annual MSF [multi-source feedback] as part
of local clinical governance processes." If so, then patient
feedback should be part of that MSF. It should have parity with
44. If patient feedback is only collected one
in five years, it will be impossible to interpret the findings
from one revalidation period to the next. Changes to results will
be impossible to assign to any of the many possible causal factors
occurring in such a long period. A five-yearly set of either good
or poor results could easily be attributed to "luck"
with a particular cohort of respondents.
45. Changes are somewhat easier to attribute
in an annual cycle. However, we note that in acute hospital trusts,
the gap of a year between results of the annual inpatient survey
became a criticism used by hospitals who felt they were having
to wait too long to measure the impact of improvement plans. As
a result, increasing numbers of hospitals are now adopting more
frequent patient experience measurement ("near real time"
feedback, monthly or even fortnightly).
46. We also ask the select committee to note
the context in which revalidation will be introduced. The government
is committed to much greater and wider use of patient experience
measurement across the NHS, including near real time feedback.
It seeks the rapid establishment of information systems that will
allow patients to see service-level reporting of healthcare quality.
47. In short, the proposals for implementing
revalidation are falling well behind the curve of the development
of patient experience information, quality information, and information
for choice in the English NHS. This is a potentially serious issue,
which needs to be taken into consideration.
48. We respectfully request the select committee
to consider Picker Institute's alternative proposals, that:
- patient feedback should be used at every annual
appraisal, and therefore collected at least annually;
- there should be formal consideration of establishing
more frequent and continuous collection of patient feedback
data, tailored to the doctor's service settings and patient characteristics
where relevant, to enable both early alerts to weak performance
on patient experience, and early assessment of the impact of any
- where patient experience data give cause for
concern, a remedial action plan for improving performance
and monitoring patients' experiences of care should be agreed
and implemented. Doctors should be required to submit real-time
evidence of compliance with the plan to their appraiser and Responsible
Officer until repeated patient experience surveys demonstrate
49. In its response to the consultation, the
GMC makes clear that it does not intend to establish a "central"
system for collecting patient feedback. It also notes that questionnaires
which it makes available will need to be administered independently.
50. These statements imply a devolved approach
in which local workplaces, or even doctors themselves, will choose
which instruments to use, how and when to administer them, what
assistance and which third parties to contract.
51. While we understand the good reasons for
wishing to devolve quality management to a local level, where
people "own" the results, Picker Institute Europe is
also conscious of the real risks this poses to the consistency
of patient experience measurement. Here we offer the benefit of
lessons from co-ordinating (and participating as a survey provider
in) the regulator's national patient surveys in both primary and
52. Staff and service settings vary considerably
in their expertise, confidence, capacity and willingness to co-operate
to administer patient feedback questionnaires consistently and
in accordance with agreed methodologies and protocols.
53. Inconsistencies are not acceptable to medical
professionals. If, for example, one doctor receives poor feedback
from his patients, but a nearby colleague or a similar specialist
is perceived to have "skated by" using a different method,
or the same method administered or reported in a different way,
there will be complaints of unfairness that will undermine the
validity of patient experience data.
54. Similarly, if one region takes a "maximalist"
approach to data collection, and another a "minimalist"
approach (in terms, for example, of numbers of patients or numbers
of questions/indicators), it will be unacceptable to those being
55. Hence whatever system is established must
be capable of delivering consistency - it is the same thing as
credibility, especially in a profession which is so ruthlessly
56. In the national survey programme, inconsistencies
are ruled out as far as possible by using a combination of devolution
- A single standard questionnaire is used, providing
"core" indicators that are comparable between the trusts
and departments being surveyed - but trusts can, should they wish,
use additional tested questions according to their own needs.
- Each NHS trust administers its own survey. It
may or may not choose to employ an independent contractor for
this. However, a rigorous administration method is laid down,
to which trusts and their contractors must adhere. Central co-ordinators
provide regular advice and assistance to trusts, as well as quality
assuring their implementation.
- A minimum sample size is stipulated. Again, however,
it is open to individual trust to seek a larger sample where they
believe it is helpful and justifiable. Larger samples produce
- There is a competitive market in survey contracting,
but within a managed "framework", which means that survey
providers must be approved for these purposes. This helps to ensure
that all independent contractors work to similar standards and
follow the approved methods.
57. We do not argue that this system must be
exactly replicated for medical appraisal and revalidation, but
we would point out the benefits of co-ordination to all parties.
58. Everyone in the system knows with confidence
that they are measuring the same things, in the same way.
59. Everyone in the system knows with confidence
that they are not being disadvantaged by any variance in the number
or character of the questions, or by undue variations in sample
60. Everyone in the system knows where to go
for advice - and that the advice they receive is the same as would
be provided to everyone else.
61. The results are comparable between all trusts
(nationally); between trusts within a region; and between trusts
of similar type, or size. Importantly, where a consistent method
is used for repeat surveys, results are comparable over time,
and can show whether performance is improving or deteriorating
on any specific indicator.
62. Local workplace organisation and administration
of patient experience measurement carries a substantial risk of
poor process, poor data quality and considerable expense.
63. Poor process can include the introduction
of bias. This is likely if staff directly involved in patient
care administer the questionnaires; or if patients complete them
while still within a care setting on which they still feel dependent.
64. Poor process can also include undue variation
in sample size, or in demographic sampling, leaving uncertainty
about the representativeness of the data.
65. With regard to confidentiality, local devolution
also carries a serious risk that individual patients will be identifiable.
66. We would therefore respectfully request
the committee to consider recommending that the General Medical
Council should review the potential benefits of a managed, co-ordinated
and quality assured system for organising and administering patient
67. Medical revalidation, and the associated
improvement in medical appraisal, have already been in development
for nearly a decade. This is too long. No further undue delays
should be tolerated. Patients expect - and have a right to expect
- that the quality of their doctors is regularly assessed and
assured. This is about the safety, effectiveness and appropriateness
of the healthcare that citizens receive.
68. The GMC's consultation proposed a phased
approach to implementation that would potentially give organisations
that are not ready an additional five years after 2011. The majority
of those responding to the consultation apparently agreed.
69. This potential extension is perverse because
it apparently licences organisations with clinical governance
systems that are not fit for purpose to continue in that state.
It is unacceptable because patients and the public expect the
NHS to have these systems in place now.
70. Picker Institute Europe believes, and asks
the committee to consider, that:
- the introduction of revalidation should drive
improvement, not encourage complacency;
- a firm target date should be set for revalidation
to go live, with the expectation that all areas and healthcare
organisations will implement revalidation from that date;
- those areas or organisations that appear not
to be ready should receive targeted assistance to achieve the
71. Roughly 18 months remain for piloting. While
the early adopters are engaged in piloting (or learning from it),
weaker organisations should be putting their systems in order.
- organisations should be required to be ready
to introduce revalidation within 18 months of early adoption;
- organisations should be required to introduce
revalidation within 24 months of early adoption.
4 Examples include the Consultation satisfaction questionnaire
(Poulton 1996); Consultation and relational empathy measure (Mercer
2004; Mercer 2005); OPTION scale for measuring patient involvement
(Elwyn et al 2003); QUOTE instrument (Sixma et al
1998, 2000). See "The quality of patient engagement and
involvement in primary care", Parsons S et al,
Kings Fund, London 2010. Back
Consent: patients and doctors making decisions together,
GMC, London 2008. Back
Tomorrow's Doctors, GMC, London 2009. Back
High Quality Care for All, Department of Health, London
Equity and excellence: liberating the NHS, Department of
Health, London 2010. Back
This evidence is published at www.investinengagement.info. Back
Capturing opinions from the front line, King's Fund, London,
See, for example, Seeing the person in the Patient, Goodrich
J and Cornwell J, King's Fund, London 2008. Back
Equity and excellence: Liberating the NHS, Department of
Health, London 2010; and An Information Revolution: a consultation
on proposals, Department of Health, London 2010. Back
We note, however, that while it remains committed to a phased
approach, no time period is specified in the GMC's own response
to the consultation. Back