IMPROVING THE PATIENT’S EXPERIENCE 1
PATIENTS’ PRIOrITIES FOR THE NHS IN WALES
Marcus Longley
Welsh Institute for Health and Social Care | University of Glamorgan
December 2009
FOREWORD
The NHS in Wales has been striving to improve the quality of care for many years. A vital part of this endeavour is the focus on the ‘patient experience’ – what it is actually like to be a patient in the NHS, and how that first-hand experience of care can be improved. This series of four papers makes a timely contribution to this work.
This first paper – Patients’ Priorities for the NHS in Wales – reports on three day-long consultation events held in different parts of the country, designed to allow patients and services users to reflect on what the ‘patients experience’ really means to them, and what would make the greatest improvement to it.
Paper 2 – Common Themes from the Literature – provides a brief summary of some of just some the key pieces of research carried out recently in the rest of the UK and internationally on patients’ priorities in improving their experience of care.
The third paper - A Review of Patient Feedback Processes in the NHS in Wales – looks at how the NHS in Wales has sought to understand the patient’s experience over the past two years. It describes the range of measures routinely used by NHS Trusts, Local Health Boards and Community Health Councils to get feedback from their patients, and considers how this work could be further developed in the future.
The final paper – How the Priorities are Influencing the Revision of the Healthcare Standards for Wales – details the top ten issues identified in Paper 1, how they fit with the revised Healthcare Standards for Wales and how the identified priorities have influenced the revision of the healthcare standards.
PURPOSE
The term ‘patient experience’ has acquired considerable currency in recent years as a way of encapsulating the way the NHS addresses the totality of patients’ needs and preferences – including both clinical and non-clinical care. It therefore embraces everything from the success of clinical interventions to issues of access, responsiveness, choice, the state of the physical environment of care, and much else.
Improving the patient’s experience of care is a key priority for NHS Wales. But what exactly do patients want to see improved most?
People’s priorities for improvement are often conditioned by personal experience (as a service user, or as a relative or friend of a service user), and by their own expectations, reports in the media, and other sources of information. As these perceptions change over time, so do people’s priorities; different issues may also have greater priority in different parts of Wales. It is important, therefore, to get an up-to-date and reasonably representative cross-section of opinion across Wales… hence the workshops reported here.
People’s priorities for improving the patient experience were explored during the course of 3 full-day workshops in May 2009 with patients and patient representatives. The workshops – held in Carmarthen, Merthyr Tydfil and St Asaph – brought together people with varied experiences of healthcare, some as CHC members, others from patient groups of various kinds, and some as individual patients, services users or carers. In small groups and in plenary they took part in facilitated discussions about which aspects of the patient experience required a priority focus from the NHS, and what sort of change was needed. Towards the end of each meeting participants were asked to select which of the various issues highlighted in discussion they thought would deliver the greatest beneficial change.
In total, 87 people attended the workshops, 27 in Carmarthen, 38 in Merthyr Tydfil and 22 in St Asaph.
The results of the three workshops are summarised below, and emerging issues are discussed at the end. A similar approach was adopted in each workshop, although a slightly different final question (‘what would really make a difference?’) was put to the Carmarthen group, to reflect the slightly different discussion which had taken place there.
There are two other papers in this series on the patient’s experience:
· Paper 2: Common Themes from the Literature summarises some of the themes which have emerged from various other recent attempts to find out patients’ priorities for improvement
· Paper 3: A Review of Patient Feedback Processes in the NHS in Wales describes the range of activities undertaken by NHS Trusts, Local Health Boards and Community Health Councils on a regular basis to understand what patients are experiencing from their contacts with the service, and what improvements they would like to see.
TABLE 1 Findings from THE Workshop on patients’ and carers’ priorities
HalLiwell Centre, CARMARTHEN 18TH MAY 2009
WHAT SHOULD BE THE PRIORITIES FOR CHANGING THE PATIENT’S EXPERIENCE IN WALES?
The following table sets out the priorities that were identified by the participants at the workshop, ranked by the number of votes each.
NUMBER OF PARTICIPANTS WHO RATED ISSUE AS ONE OF THEIR TOP 7 PRIORITIES / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17Patients as focus of care – e.g. answering the bell quickly when patients ring for the toilet, staff having time. / 17
Appropriate signposting through services and options discussed with patient / 9
Avoid breakdowns in communication between NHS and Patients e.g.
Doctors should give patients information with a nurse present to help patients to understand what is happening and why.
§ Avoid jargon, use of plain language of choice
§ Patient diaries
§ Patient held care plans / 7
Equity of access to GPs / 6
Parity with private care / 5
Staff Manner / 5
Patients/Carers as partners in healthcare collectively / individually-the service seeks and uses their knowledge / 5
Access to primary care when needed 24/7 / 5
Quick and easy access to diagnostics – no delay in identification and treatment / 4
Fear of not being listened to and no action / 3
Embrace complaints and find other ways for issues of concern to be dealt with. Allow anonymity / 3
Do something – not another list / 3
Re-balance patients emphasis between professionals / 3
Include carer and patient in access to consultant in hospital / 2
Reduce language barriers (all professions) Welsh / All non English / 2
Assessment starts on admission with chronic conditions. Discharge planning starts early / 2
Communication of patient’s information, notes available for appointments and accountability for this. / 2
Make opportunities for 1:1 interaction re patient experience – “What could we do to make this better”, Continuity, Time / 2
Access to minor surgery locally and consistency between surgeries. / 2
Communication and administrative skills (especially reception) / 1
Continuity of care (2nd and primary care) / 1
Timely discharge / 1
Re-balance clinical and managerial processes / 1
Timely referral to secondary care / 1
Recognise value of complementary approaches e.g. art / 1
GP as gatekeeper – often is the only point of access. / 1
Access to food in hospitals 24/7 / 1
Inappropriate questioning in some services e.g. Ambulance / 1
Dental appointment systems / 1
Clear instructions – preparation for treatment / 1
GPs automatically visit at home on discharge / 1
Information services, management, self care. / 1
Sensible appointment times; patients are responsible for their attendance, and recognise the value of the appointment (not taken for granted) / 1
Cost effectiveness analysed and actioned / 1
TABLE 2 Findings from THE Workshop on patients’ and carers’ priorities
HalLiwell Centre, CARMARTHEN 18TH MAY 2009
WHAT WOULD REALLY MAKE A DIFFERENCE?
Once participants at the workshop had identified their priorities for changing the patient experience, these were discussed to determine what actions would really make a difference to patients and their carers. The following is a summary of the measures that were identified in that discussion.
· Stop targets – patients are being discharged too early because of targets.
· Health & Social care has to happen: social care budgets to transfer to NHS.
· Standardisation of GP services across the board – parity, including access when needed.
· Patients to be aware of what they’re entitled to: written ‘Care Plan’ (patient specific) to take to next stage of care/ rights / include carers.
· Help patients to use services appropriately.
· Practical use of the key information that is (most) valuable in times of stress.
· Patients involved in therapeutic / artistic processes.
· Better / more attractive environments for care.
· Improved provision of service for dementia (all aspects)
· Motto “ Do your best and follow your gut feeling”
· Give assurances about NHS in future – not 2 tier system.
· Effective mechanism to link quality of all aspects of patients experience with GP pay (could involve a mediator)
· Give QOF teeth: independent monitoring and control to ensure things change. Link GP’s remuneration to the quality of their services.
· Independent survey of sample of patients post discharge: link results with action to improve.
· Give people information on developments and improvements that have been made (look back down the mountain).
· Make patient experience part of core business of new LHBs.
· Reduce referral threshold for MH service users. Reduce over- reliance on voluntary organisations and improve care in the community e.g. through group therapy.
table 3 Findings from THE Workshop on patients’ and carers’ prioritiesorbit Centre, MERTHYR TYDFIL 19TH MAY 2009
WHAT SHOULD BE THE PRIORITIES FOR CHANGING THE PATIENT’S EXPERIENCE IN WALES?
The following table sets out the priorities that were identified by the participants at the workshop, ranked by the number of votes given to each. /
/ 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 /
Review Nurse training (allow for EN-type role) / 21
Consistency of GP service provision / 17
Carers not included in care / 12
Ineffective communication in consultation / 10
Physical access to hospitals and GPs – Car parking / 10
Teaching Trusts to educate doctors on patient / carers experience / 10
Older people assumed to be incompetent / 8
Too scared to whistle blow / 8
Appropriate regard to carers’ capacity and age / 7
Standards of general practice are clear and there is accountability / 7
Un-coordinated elements of service / 7
Support for third / voluntary sector / 6
Promote patient’s independence whilst in hospital e.g. toileting to prevent /reduce incontinence / 6
Practice/ community nurse potential not appropriately used / 5
Avoid Jargon / 5
Staff don’t really find out what patient wants / 5
Service sign-posting / 5
Cross infection procedures: staff / 5
GP appointment times not convenient / 5
Privacy in reception / admission / 5
Pooled budgets/ extend social care, inter agency communication / 4
OT & patient assess patient’s home together / 4
Food and drink in hospital / 4
Staff gossiping over patients / 4
Transport to (GP) practices & hospitals / 3
Reluctance by GPs and Consultants to give leaflets / signpost e.g. for dementia support / 3
Clarify / confirm patients’ responsibilities for own health / 3
Prevent re-admission / 3
Appointment issues: process and notification / 3
Training:
− out of hours GP e.g Catheterisation
− Student doctors
− GP receptionist / 3
Hierarchies e.g. nurses don’t always challenge Consultants’ decisions / 2
Patient : patient and volunteer : patient support / 2
Ambulance response times / 2
Continuity of Professionals in a patient’s care / 2
Emotional well-being, affected by e.g. access problems, lack of welcome. / 2
GPs need to take holistic approach / 2
Honesty / 2
Planned operations – is there is a bed available? / 1
Rapid response teams / 1
Tell patients about GPs’ specialism’s / 1
Complaints procedure is complicated / 1
Environments and systems that promote confidentiality / 1
Patents reluctant to ask / 1
Staff too busy / 1
Patients treated as diagnosis / 1
Dental charges: unclear, too expensive / 1
Access for disabled people (misuse of car parking) / 1
Reassurance / 1
No Mixed sex facilities / 1
TABLE 4 Findings from THE Workshop on patients’ and carers’ priorities
orbit centre, merthyr tydfIl, 19 may 2009
WHAT AREAS OF IMPROVEMENT SHOULD WE FOCUS ON IN EVALUATING THE PATIENT’S EXPERIENCE?
Once participants at the workshop had identified their priorities for changing the patient experience, the top six priorities were further discussed to consider how they might be achieved. The following is a summary of the measures that were identified in this discussion.
REVIEW NURSE TRAINING (21 votes)
§ Reinstitute enrolled nurse grade, or if not make sure that when nurses qualify they are able / willing to be involved in fundamentals of care for patients.
§ System demands that they do this.
§ Get nursing resource where it’s needed.
§ Nurses are generally over qualified.
§ Would affect other issues e.g. toileting / feeding.
CONSISTENCY OF GP PROVISION (17 votes)
§ Need strong contract.
§ Evidence good practice.
§ Naming and shaming / praising.
§ Role for healthcare standards.
§ Change GP status as independent?
§ Change payment system.
§ Make QOF more public.
§ Make it easier to switch practice
§ Promote patients’ panels.
§ Survey patients e.g. via carers centres.
CARERS NOT INCLUDED IN CARE (12 votes)
§ Promote well-being of carers – avoid burn-out.
§ Publicise good practice.
§ Training.
§ Provide information.
§ Acknowledge role of carers and include in discussions as a matter of course.
PHYSICAL ACCESS (10 votes)
(Hospitals, GPs, Car parking)