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Ian Miles, PREST – a note for PUBLIN - February 2005
Note: there is a huge volume of material on this topic. At this point, I have presented the main bodies of work in some detail, quoting extensively from the original sources, and drawing heavily on these sources in the rest of the text. Every effort has been made to make the origin of material self-evident. There are also a number of points where commentary and critique have been presented: the aim has been to make it evident where the points are original to this note and where they are drawn from other sources.
There is a wide range of surveys conducted around the NHS, at national and local levels. This is almost certainly one reason for the reluctance to commit to the PUBLIN survey within the organisations we have visited. There is a sense that the scene is somewhat oversurveyed.1 In any case they are used to working with specific survey organisations, and enlisting these to pursue specific lines of enquiry. (Another important factor has been the high political and media profile of health services in the UK, which has made managers very cautious about supporting research that could be seen as yielding bad news.)2 The importance of concerns about public health services is relatively easy to demonstrate. Stories about the health service are a regular feature of the daily news, and on the day in which this paragraph was being composed the two main political parties’ election campaigning theme actually centred on details of hospital organisation (specifically whether clinical staff would be able to overrule managers in having wards closed down on grounds of hygiene). Further evidence comes from a regular survey undertaken by MORI concerning political concerns in Britain. Figure 1 reproduces a telling graph reproducing results from a question asking people to identify the most important issue facing the country. It is apparent that the health service (NHS=National Health Service) has been a dominant concern for most of the last decade (at least). The trend line suggests that this importance is, if anything, growing (though not as rapidly as concern with crime/law and order). There has apparently been a recent decline in concern with health as a local issue (see the second graph), but for most of the
While writing this essay the author was discussing completely unrelated issues with an NHS physiotherapist, who launched into a completely unprompted tirade about the evaluation questionnaires she was continually being confronted with in the NHS (and, indeed, in other welfare organisations she worked with). 2 A rather different point is that the formulation and design of the PUBLIN survey is not immediately appealing to the people we have contacted, who find it hard to see its relevance to their concerns.
period covered it has been the second most important topic (behind crime – which has again shown a fairly clear upward trend). Figure 1 Political Concerns in Britain around the turn of the Millennium
source: Barry Quirk “Handling the Perception Gap” Cabinet Office Public Service Reform Seminars, 28 May 2004 at: http://www.cabinetoffice.gov.uk/opsr/documents/pdf/barryquirke_percep.pdf The use of surveys as indicators of the quality of health services, and as providing reasonably objective data against which performance could be assessed, is itself an important organisational innovation in the NHS. It is, perhaps, fitting that that health sector, whose emphasis on clinical trials and health technology assessment provided a strong model for the phenomenon known as “evidence-based policymaking”, has itself been one of the areas of public services that has been in the vanguard of the application of these particular tools for generation of evidence. Though much of the material reported below is in the form of simple tabulations and assessments of change between time periods, there is considerable work going on to establish the dynamics that
lie behind the results – both in terms of perceptions, and in terms of the aspects of health services that are being perceived and reported on. We mentioned above that there are many surveys focusing on NHS staff and patients. We shall see below that there are some remarkably sophisticated and large-scale surveys undertaken for the NHS itself, as well as for other policy agencies. A range of other bodies also commission and undertake research. The British Medical Association, for instance, is responsible for a number of studies of issues such as work organisation in the NHS.3 The existence of a range of surveys may make some people feel “oversurveyed” – but it does mean that there is material that can be reviewed, insofar as it is in the public domain. And indeed, a good deal of material is available to the general public, and not just to specialist researchers. This note briefly reviews available material and the conclusions that can be drawn from it. It begins with a survey that directly concerns one major IT (Information Technology) innovation, and then goes on to consider the surveys of staff and of patients/consumers 4 that have been undertaken recently.
Doctors’ Views on the National Programme for IT
Health issues are politically prominent, and are thus often examined in social attitudes and related research. The issue of innovation is not usually prominent, unfortunately. In many of the results discussed later in this essay, the role played by innovation – and if so, which innovation and which type of innovation – is extremely hard to establish without insider knowledge of the cases at hand. However, there are instances where innovation-related matters are treated explicitly. For instance, the controversial issue of the NHS’s ambitious new Information Technology scheme – the National Programme for IT (NPfIT) - has received some recent attention. The Medix survey Q647 was carried out at the end of January 2005 by the firm, Medix.5 It was commissioned by bjhc&im (The British Journal of Healthcare Computing & Information Management),6 Computer Weekly,7 the Guardian (a quality daily newspaper)8 and E-Health Insider (a business service to media
See http://www.bma.org.uk/ap.nsf/Content/Hubhealthcarepolicyresearch The term “consumer” unsettles many people, who see it as another step in the move away from the ideal of public services, to health being treated as something that is just another commodity. However, “patient” is clearly too narrow, since many other parties (nor least family members) are liable to be involved in medical decisions and processes, and affected by their outcomes. 5 http://www.medix-uk.com/home/index.html 6 http://www.bjhc.co.uk/index.html - an introductory page populated with topical stories on health informatics issues. 7 http://www.computerweekly.com/ 8 http://www.guardian.co.uk/
reporting on health issues, promoting “editorial excellence in e-health”… “working with editorial content accurately and with insight, writing in a jargon-free way and really understanding the needs of clients and readers”.9 The survey was fifth in a series (the first in February 2003) designed to investigate the (changing) views of doctors in England about the NPfIT. It was an online survey. There were 900 respondents, about 1% of relevant doctors, representing “a wide and wellbalanced range of specialties … in terms of grade, commitment and decade of qualification … a good representation of practising doctors on the GMC register, with some bias towards general practice.”10 The headline result was that doctors (and especially GPs), are tending to become less supportive of NPfIT. In 2004, for example, 70% of GPs thought it was an important NHS priority and 56% were enthusiastic about it. In 2005 the respective figures are 41% and 21% - a halving of the share of enthusiasts among doctors. Furthermore, one area where change would have been hoped for has instead remained fairly constant: doctors continue to report having little information about NPfIT, and while 86% consider consultation with individual doctors to be important, 71% have had none (and only 5% say that they have had adequate consultation). 31% of doctors report having no information about NPfIT (5% actually suggested that the survey was the first they had heard of it); only 4% claim to have had a lot of information (This is an increase on the compared to 1% of 2003, but still a very low figure). One interesting result in terms of innovation processes is that a large majority of respondents (81%) believed that it is important to align local working practices with NPfIT before it is introduced locally (only 4% consider this to be unimportant). The decline in support for NPfIT over the past year was seen by Medix as likely to stem from (continuing) poor levels of consultation: “It may be that, as new services become available and can be seen and used, that decline will be reversed and enthusiasm reignited. However, the responses to Q7 (re the importance of individual consultation) and Q8b (re the need for early consultation) suggest that it would be dangerous to rely on that approach. It seems likely that, if levels of understanding of the advantages of NPfIT amongst individual front-line doctors, especially GPs, are massively increased by rigorous, interactive, detailed and widespread communication, support and enthusiasm for NPfIT would strengthen….” Some main results of the survey are presented in Boxes 1 and 2
http://www.e-health-insider.com/about_us.cfm Medix UK plc survey (Q647) of doctors’ views about the National Programme for IT (NPfIT) Report on findings; 2004; available at: http://image.guardian.co.uk/sysfiles/Society/documents/2005/02/08/survey.doc
BOX 1 Some highlights of the survey (selected by Medix)11
•After two and a half years, 64% of doctors have little or no information about NPfIT, 5% saying that the survey is the first they have heard of it. Only 4% have had a lot of information – no better than a year ago. •Only 5% of doctors say they have had adequate or more consultation – 71% have had none. These findings have hardly changed over two years. •89% of doctors say that early consultation is more effective than waiting until there are working systems available to show them (which seems to be NPfIT policy) – only 3% disagree. •Only 13% of GPs think that, in the long term, NPfIT will significantly improve clinical care – 2% in the short term. •A year ago, 70% of GPs said that NPfIT was an important priority for the NHS. Now only 41% do so. •Only 21% of GPs (51% of non GPs) are enthusiastic about NPfIT – down from 56% and 75% a year ago. •61% of GPs say Choose and Book is unimportant – only 11% think it’s important. •A year ago, 58% of GPs (66% of non GPs) said that the Care Records Service was very important. Today that’s down to 20% and 34%.12 •70% of GPs (42% of non GPs) think the Care Records Service will lessen patient record security – only 6% (18% of non GPs) think it will improve it. •79% of GPs agree with a recommendation that they should not engage with the Care Records Service until concerns re confidentiality etc. are met.
The two boxes here reproduce sets of bullet points in the Medix report. There has been a limited amount of rephrasing to aid readability – and a few loaded terms have been removed from the accounts. 12 There was much more enthusiasm for the NHS Care Records Service than for Choose and Book: 59% of GPs (73% of non GPs) consider the Care Records Service to be important or very important. In contrast only 11% (GPs) and 28% (non GPs) consider Choose and Book to be important or very important.
BOX 2 Contrasts between GPs and Other Doctors (selected by Medix)
: Regarding NPfIT’s likely effect on clinical care in the longer term, 36% of non GPs expect significant improvement – but only 13% of GPs agree. Likewise, regarding the likely effect on a doctor’s working life in the longer term, 28% of non GPs expect significant improvement – yet only 9% of GPs do so. Moreover, 13% of GPs expect a significant worsening compared with only 4% of non GPs. 68% of non GPs think that NPfIT is an important or very important priority for the NHS – only 41% of GPs agree. Whereas only 28% of non GPs think “Choose and Book” is important, a mere 11% of GPs (who mainly will be expected to operate the system) agree – hugely outnumbered by the 61% who think it’s unimportant13. When asked if the Care Records Service would be likely to mean that the confidentiality of patients’ records would be more secure, only 18% of non GPs thought it would. That may be bad enough – but far worse is the finding that only 6% of GPs think so. Respondents were asked if they agreed that GPs should not engage with the Care Records Service until specified concerns were met,14 59% of non GPs agreed, compared with GPs at 79%. When asked about their likely level of support for NPfIT, 42% of non GPs say they are fairly enthusiastic and 9% very enthusiastic – but, for GPs, only 19% were fairly enthusiastic and a mere 2% very enthusiastic. A year ago the equivalent figures for GPs were 36% and 9%.
A year ago the latter figure was 47%. This was the position adopted by delegates at a GP conference at the BMA in 2004. However, the NPfIT insists that confidentiality – one of the main concerns - will be secured (and to a greater extent than at present) by the new systems. Medix thus speculate that the attitudes may reflect lack of consultation and of understanding. When asked if they thought that the advent of the NHS Care Records Service was likely to mean that the confidentiality of patients’ records will be more or less secure than it is today. 70% of GPs (42% of other doctors) thought it would be less secure and only 6% (18%) more secure.
The Medix Survey met with a forthright response from the NPfIT.15 criticised the sample size and presentation of the data:
“The Medix survey is based on less than 1% of clinicians and its commentary highlights negative aspects of the survey and focuses on the GPs' responses whereas other doctors are more positive.” More substantially, perhaps, the response argued that the NPfIT has embarked on exactly the kind of reinvigorated clinical engagement programme that the Medix study recommended, stating that: “We know there has been some discontinuity in our clinical engagement. But we have recently adopted a new approach, appointing a number of senior clinicians to lead this engagement work…. The Medix survey was conducted in the period after the appointment of these new clinical leads but well before their work has had the chance to penetrate at grass roots level….The new clinical leads are already building up momentum, developing new relationships between NPfIT and key clinical stakeholders and a range of approaches including joint activity with the British Medical Association. It will take time but their engagement is accelerating….NPfIT is about improving patient care. Over time NPfIT will bring about great improvements in the safety and efficiency of patient care and reduce the administrative burden on healthcare professionals. The survey recognises this: 40% of GPs and 68% of other doctors say NPfIT will in time lead to an improvement in clinical care.”16 This controversy is interesting for what it tells us about processes of technology introduction in the NHS. It also helps us see why conducting surveys in the NHS can be rather a fraught activity. We will now review the surveys of NHS staff, before turning to those that concern patients and “consumers”.
http://www.npfit.nhs.uk/news/080205/view But the Medix highlight reported above suggested that a “significant” improvement was anticipated by only 36% on nonGPs.
The Commission for Health Improvement
The legacy site run by the Commission for Health Improvement (at http://www.chi.nhs.uk/eng/surveys/nss2003/index.shtml#04 ) describes survey undertaken by CHI before The Healthcare Commission took over this role on March 31st 2004,17
The Healthcare Commission
The Healthcare Commission (its legal name is the Commission for Healthcare Audit and Inspection) was formed by the Health and Social Care (Community Health and Standards) Act 2003, and launched on April 1st 2004. It has a rich website (http://www.healthcarecommission.org.uk/Homepage/fs/en ) which explains that the Healthcare Commission has been set up ”to promote improvement in the quality of healthcare in England and Wales”. (Note: this does not include Northern Ireland and Scotland, which are also part of the UK; and in England only the Commission work also includes regulation of the independent healthcare sector.) The staff surveys are believed to be among the biggest, if not the biggest workforce survey in the world. The 2004 staff survey results are available later in 2005 18 but the results for 2003 are already available – in considerable detail, with annexes on topics such as the psychometric attributes of the scales used. The notes below mainly draw on the Summary Report, Summary of the analysis of the 2003 NHS staff survey (2004).19 The survey was undertaken by a group at Aston University Business School. The objective is to provide information about the attitudes and experience of staff to NHS employers, policy makers and national regulators. This should enable assessment of the performance of the NHS as employer(s), and monitoring of the implementation of national policies to improve the working lives of staff. (The argument is elaborated that staff attitudes and morale are major influences on patient care.) It should be noted, however, that the survey respondents were only direct employees. Other people who provide NHS care under contract, in particular, GPs and their staff, were outside the scope of this particular survey. 203,911 NHS employees responded (this was 56% of those invited), and 57s organisations took part, covering all types of NHS organisation in England (nb –
The new body also assumed the private and voluntary healthcare functions of the National Care Standards Commission (also wound up on March 31st 2004), and those “elements of the Audit Commission’s work which relate to efficiency, effectiveness and economy of healthcare”. 18 http://www.healthcarecommission.org.uk/NationalFindings/Surveys/StaffSurveys/fs/ en? CONTENT_ID=4000125&chk=3p67/v 19 http://www.healthcarecommission.org.uk/assetRoot/04/00/77/48/04007748.pdf
not Scotland, Wales, Northern Ireland) - including acute and specialist trusts (primarily providing hospital services), mental health trusts, ambulance trusts, and primary care trusts (PCTs – these have responsibility for primary care and community services.)20 The survey examined the following issues: ♦ Work context o organisational climate o senior management leadership o work life balance o working extra hours o flexible working opportunities ♦ Management of people o quality of job design o support from supervisor o incident reporting procedures o dealing with violence or harassment o appraisals o personal development plans o team working o training and development ♦ Safety at work o work related stress o work related injury o errors/near misses witnessed o violence/harassment/bullying from other staff o violence/harassment from patients or relatives o reporting of violence/harassment/bullying ♦ Attitude of staff o job satisfaction o staff intention to leave jobs o work pressures Box 3 presents highlights of results around these four areas. Box 4 concerns differences between the various types of NHS organisation, and Box 5 deals with the views of different occupational groups.
Clearly, if there are substantial differences in results from one class of NHS organisation to another, this will have profound implications for any smaller-scale survey investigations of innovation in this sector. Even the question of clarifying which organisation the respondents see themselves as working for and describing in the survey is a potential minefield.
BOX 3: Some Key Results of the Staff Survey The following results are highlighted in the Summary Report, and are quoted here with only minor formatting changes: Work context ♦ Three quarters of NHS staff report routinely working more than their contracted hours; one
in 10 work over 10 hours more than they are contracted in an average week. On the other hand, almost two thirds of staff thought their employer was making efforts to address the balance between work and private lives. Staff views on organisational climate are more positive than negative overall. Furthermore: • staff are particularly positive about their organisations support for improvement in services and focus on patients; • they are less so about communication within the organisation and involvement in decision making; • the leadership of senior management was rated positively
Management of people ♦ The quality of job design, including job content, feedback and involvement, and support
from supervisors is higher in the NHS than other sectors. Encouragingly, almost all staff (93%) are aware of how to report incidents of errors or near misses that could harm patients or staff, and the vast majority (85%) feel that their employer encouraged such reporting. Similarly, high levels of staff know how to report harassment or bullying. However, of the staff who said they had experienced harassment, bullying or abuse, only half had actually reported it; even where violence was involved, only two thirds had reported the events. Three fifths of staff reported having an appraisal in the previous year. Just over a third of these reported having a well structured appraisal – one in which they felt clear work objectives and ideas for improvement had been discussed, and which left them feeling that their employer valued their work. During the last year, nine out of 10 staff have received some form of training and development, although only two fifths have received health and safety training. Nine out of 10 respondents said they work in teams. Further questioning revealed that only two fifths considered these teams are small and well structured and meet regularly enough and work closely together towards clear objectives.
Staff attitudes ♦ Three quarters of staff said they are generally satisfied with their jobs, compared to two ♦
thirds found in similar surveys of other sectors. However, half feel under pressure at work. More than a third said they often think about leaving their current employer, and a quarter said they would probably look for a new job in the next year. Half of all staff agreed or strongly agreed that if they did leave their current job, they would want to stay in the NHS.
Safety at work ♦ One in five staff reported some injury or illness as a result of one or more of the following
problems at work in the previous year: moving and handling; needlestick and sharps injuries; slips, trips or falls; and exposure to dangerous substances. Two fifths reported suffering from work related stress in the previous year. Nearly half said they had seen at least one error that could have hurt either staff or patients in the previous month. Over a third of staff have experienced harassment, bullying or abuse at work in the previous 12 months. This was mainly from patients and relatives, although some was from
colleagues or managers. One in six respondents reported experiencing physical violence at work in the previous year.
BOX 4: Variations across the NHS in the Staff Survey The Summary Report: notes important differences in the views and experiences of NHS staff working in different parts of the organisation. The most negative group of staff were Ambulance Staff, in almost all aspects of work. They reported worse work life balance, lower support from supervisors, and more negative views concerning organisational issues, health and safety and training. The Summary Report pays particular attention to the experience of violence, harassment and bullying. While a common problem (and one that has attracted a good deal of media coverage), it is one whose incidence is very uneven across different groups of staff. “• nearly a third of all staff in ambulance trusts, and over half of paramedics and ambulance technicians, experienced violence from patients or their relatives in the last year • a quarter of staff in mental health trusts, and half of unregistered nurses and healthcare assistants, have experienced violence from patients or relatives • nurses and healthcare assistants in acute trusts and PCTs, are more likely to experience violence than other staff In general, those groups who experienced the highest levels of violence are most likely to report these incidents. However: • only two thirds of staff in ambulance trusts reported incidents, compared to nine out of 10 staff in mental health trusts • doctors and midwives were also less likely to report incidents.” “The pattern for harassment and bullying is broadly similar, with the highest levels in ambulance and mental health trusts, for shift workers, nurses and healthcare assistants. Harassment and bullying by colleagues and managers was found to be highest in ambulance trusts, with one in five staff reporting they have experienced this in the last year.” (emphases added)
BOX 5: Variations across Occupational Groups in the Staff Survey The Summary Report: notes that across different types of organisation (trust) there are important differences between occupational groups: “• Nurses report high levels of support from supervisors, and good access to training. However, nurses and healthcare assistants are much more likely to experience violence from patients than other groups of staff, except those in ambulance trusts. Nurses also experienced high work related stress, and are more likely to say they plan to leave their jobs • Doctors of all grades report high work pressure and low support from supervisors. Although a high proportion of doctors and dentists have received appraisals, a low proportion thought appraisals are well structured. Consultants report high levels of stress, and are likely to see errors or incidents • health visitors and allied health professionals have high levels of appraisals and training, but report high work pressure, and high work related stress, as do midwives • Ambulance technicians and paramedics report low levels of support from supervisors and high levels of violence from patients • Maintenance and ancillary staff are less likely to have had an appraisal, training or work in a team, and are likely to have poorer work life balance, and are more likely to say they plan to leave their jobs, than most other staff groups • Administration and clerical staff show a similar pattern to maintenance and ancillary staff, with fewer having appraisals or training, and a high proportion of staff planning to leave their jobs • General managers reported a positive experience overall but more report working extra hours due to pressures of the job than other staff groups” … ”• Shift workers, who constitute nearly a third of NHS staff, also report negative experiences, poorer work life balance, less team working, poorer job design and less job satisfaction. They are up to seven times more likely to experience violence, and also to see more errors and incidents.” (emphases added) “Almost no variation was found between staff on the basis of age, gender, ethnicity or disability, after differences in job type and working arrangements were taken into account. In particular, there were no differences in experience of bullying or harassment between staff from different ethnic groups. However, there are substantial differences between ethnic groups in the types of NHS jobs they do and their working arrangements. In particular, there is under representation of black and minority ethnic staff in ambulance trusts.”
The survey data have been subject to detailed analyses, identifying linkages between the work context and management of people factors, on the one hand, and staff attitudes and experiences of safety at work. The Report reveals that the particularly important factors were: “• organisational climate (communications, involvement, support for improvement, focus on patients)” – a positive climate is strongly associated with higher levels of staff satisfaction. • quality of job design (job content, feedback and involvement) • support from supervisors • effective systems for reporting and addressing health and safety issues “ Other results included that: “• Staff who are positive about their organisation report lower levels of work related stress and injury, and experience lower levels of harassment, bullying and violence at work…. • staff who feel they get support to balance their work and private lives report higher levels of job satisfaction, lower work pressure, and are less likely to say that they will leave their current job • staff who work extra hours report higher levels of work related injury, and harassment, bullying and violence at work • staff are more satisfied with their jobs and less likely to want to leave an organisation if they are satisfied with senior management … • staff who have a high quality of job design are much more likely to be satisfied, less likely to plan to leave and less likely to experience pressure at work. A high quality of job design is also related to lower levels of stress and injury, and lower levels of harassment, bullying and violence at work. … • staff who feel supported are more satisfied in their jobs, less likely to plan to leave, and less likely to experience work related stress. Well structured appraisal and personal development plans are also positively related to staff satisfaction at work. • Staff who are more positive about the fairness and effectiveness of reporting systems also stated that they had seen fewer incidents and work related injury. Similarly, staff who perceive that their employer would deal effectively with violence, harassment or bullying, experience lower levels of such events.” (Text slightly reformatted.)
The UK is a highly surveyed country, and NHS workers (and related health sector workers) are undoubtedly sampled in a large number of surveys which are not directly intended to elicit information about their sector. Some of these are cross-national surveys, and in principle their datasets could be mined for the sorts of comparative data that PUBLIN is interested in – though we are aware of few surveys that directly tackle innovation issues. (One exception if in the use of Labour Force Surveys, which in Nordic countries have been used to investigate the diffusion and use of new information technologies.) Nevertheless, we would draw attention to the outstanding data source that is the European survey on working conditions, from which detailed data for the year 2000 is available – though the main report collapses together health, education and social service workers.21 This survey carries data on many features of work organisation, such as whether employees have influence over their working hours; are continuously working at high speed or to tight deadlines; have their pace of work induced by direct customer demand; are engaged in monotonous tasks; learn new things on the job; can/cannot obtain assistance from colleagues when required; and other topics such as whether their skills match their job demands and whether they have received training in the last year. It is possible to achieve a great deal in terms of sectoral, cross-national, occupational, gender and other analyses, from these data. There are also many national surveys of interest, that will include some health service workers in their samples. One of the longest-established is WIRS, the Workplace Employee Relations Survey (previously known as the Workplace Industrial Relations Survey, WIRS), which has now been through several iterations (from 1980 to 1998, with a 2004 survey due for deposit in June 2005). 22 In earlier incarnations, it includes data based on survey responses from managers, workers and workers' representatives at establishments employing 5 or more people, focusing on industrial relations (from management and union sides), industrial action and – relevant to PUBLIN - technical and organisational change. The coverage should be around 2,500 workplaces, with self-completion questionnaires will be returned by around 30,000 employees. To date, we know of no specific analyses of health sector workers carried out via WERS. It is possible that sample sizes will be too limited to make for detailed analyses, though the public sector as a whole may be more amenable to study. (To the extent that such analyses are possible, the WERS surveys make it feasible to compare workers in these sectors with those in others.) The survey
Available (with many supplementary documents) from the European Foundation in Dublin – see http://www.eurofound.eu.int/publications/files/EF0121EN.pdf for the main report. 22 See http://www.dti.gov.uk/er/emar/wers5.htm
has been used substantially in the past to track technological change and its relation to workplace affairs, though experts in this area have complained about shifts in focus of the survey making it less useful for these purposes. The current employee questionnaire does have a series of questions about computer use, and some about how change is introduced in the workplace (how good managers are at keeping you informed about “change in the way the organisation is being run” “change in how you do your job” etc), but does not specifically talk about innovation, nor technological changes. The management questionnaire is more detailed concerning change, enquiring whether the management has introduced each of the following classes of change, and how great an impact it has had on the workforce: Introduction of performance related pay Introduction or upgrading of computers Introduction or upgrading of other types of new technology Changes in working time arrangements Changes in the organisation of work Changes in work techniques or procedures Introduction of initiatives to involve employees Introduction of technologically new or significantly improved product or service
The study also examines how far workers and consultation committees have been involved in consultation, etc., about the changes. There are a host of other surveys which probably have some bearing on the topics of concern. The most scholarly of these are deposited for general use in the University of Colchester’s Data Archive.23 Material from private consultancies is much less often available, though some consultancies publish extensive tabulations from their analyses. We are not able to review the whole range of this material here.
Patient and “Consumer” Surveys
The Commission for Health Improvement
The Commission for Health Improvement (CHI) conducted the national NHS patient survey in 2003, which focused on (1) experiences in primary care trusts, and (2) in outpatient and accident and emergency (A&E) departments in acute trusts.
The Healthcare Commission
The Healthcare Commission also conducts patient surveys.24 The documentation explains that the results of these patient surveys, providing detailed information on how patients feel about the service they receive, enter as performance indicators within the “balanced scorecard” performance ratings of all NHS trusts. The acute, mental health and ambulance survey performance indicators are included under the "patient focus" area, and the primary care trust survey indicators are in the "access to quality services" area. Results of surveys undertaken in autumn 2004, asking patients about their experience of (1) accident and emergency departments and (2) outpatients services are being analysed and should be published in spring 2005. (The questionnaires for these surveys are available on the website). Details of the National NHS patient survey programme 2004 are available at the time of writing, however. Indeed, a rich set of publications is online: ♦ ♦ ♦ ♦ ♦ ♦ ♦ A combined summary of the findings from all 2004 patient survey: Acute trusts: Inpatient patients survey 2004 Acute trusts: Young patients survey 2004 Primary care trusts: Primary health care trust survey 2004 Mental health trusts: Mental health survey 2004 Ambulance trusts: Ambulance patients survey 2004 Evaluation of the 2004 National NHS Patient Survey (undertaken by an independent research agency, SSMR, and based on detailed interviews with 25 trusts, six approved contractors, five strategic health authorities and the survey teams at the advice centre.)
The following account draws mainly on material from the first of these reports.25
see http://www.healthcarecommission.org.uk/NationalFindings/Surveys/PatientSurveys/fs/ en? CONTENT_ID=4000117&chk=XPJRIh 25 http://www.healthcarecommission.org.uk/assetRoot/04/00/81/84/04008184.pdf
Five national surveys were undertaken, covering 568 NHS organisations and 312,348 patients across England.26 These examined patients’ experiences of different NHS services. Two surveys, the adult inpatient and primary care services surveys, replicated earlier studies; three (the young patient survey, survey of mental health service users and the ambulance survey) are the first such national surveys. The five Boxes below (Box 6 – 10) summarise results from these surveys as presented in the “combined summary” report. No doubt these results have been selected for attention because of the policy concerns prioritised by the HC staff. In particular there has been much discussion of issues such as waiting times, where the performance of the NHS has been a source of party political point-scoring. The combined summary report draws attention to consistent themes repeated across the NHS. It is encouraging to see that “the overwhelming majority of patients rated their care very highly”, reported being listened to, and being treated with respect and dignity. Communication with individual doctors, nurses and other clinical staff was seen very positively on the whole. Clinical staff are trusted by, and have the confidence of most patients The study paid particular attention to areas of practice where improvements or deteriorating conditions were reported (as compared to earlier data). Waiting times have been a particular hot issue in the UK, and improvements are reported here – which are “ahead of public perception of waiting”. In contrast ratings of the cleanliness of toilets and bathrooms went down – and this has now emerged as a topic for party political rhetoric. (It seems likely that these survey results are pored over by political advisors to the main parties.) Patients with more complex and ongoing needs are believed to be reporting lower levels of satisfaction with the services they receive. This may in part account for the more negative experiences of long term users of mental health services.
“The questionnaires and methodology were developed by the NHS surveys advice centre at Picker Institute Europe, which provided support for trusts in carrying out the surveys. The questionnaires cover issues that are priorities for patients, and were developed and tested in partnership with patients. Each trust that took part identified 850 eligible people. Patients were sent questionnaires, and up to two reminders. Response rates to the surveys varied from 63% for the adult inpatient survey to 42% for the mental health survey.”
BOX 6 Key Findings from the Adult inpatient survey The 2004 Adult inpatient survey follows on a first survey (published in 2002): In 2004 over 90% of people rated their care as excellent, very good or good. Areas where services have improved since the 2002 survey: ♦ Fewer emergency patients had to wait a long time before being admitted to a room or ward. (26% had to wait more than four hours – down from 33% in 2002.) The view of patients was that the organisation of care in emergency departments had improved. Increased numbers of patients reported that they “got answers they could understand” from nurses. Increased numbers of patients felt that there was an opportunity for their family to talk to a doctor.
♦ ♦ ♦
The survey also reveals some areas that are more problematic - in its words, areas where “there was an increase in the number of negative experiences reported”: ♦ ♦ ♦ Fewer patients reported that they received the results of tests on time, Or that the purpose of medication was explained, Or that thought that toilets and bathrooms were very clean.
The survey report thus concludes that despite improvements, and despite the continuing high degree of confidence and trust of patients in doctors and nurses, the survey indicates areas where there is room for improvement in the basic standards of care. These are: ● the hospital environment, where levels of cleanliness, noise, lack of privacy and mixed sex wards remain a problem for some patients; ● information for patients and their involvement in and understanding of their care (it is noted that this is fundamental to patients giving consent to treatment and exercising choice – choice has become a critical goal in NHS policy today); ● delays on the day of discharge home from hospital, and inadequate advice about medication side effects, problems to look out for, and when to resume activities of daily life.
BOX 7 Key findings from the Young Patient survey This questionnaire was completed “by the patient themselves, by patients with their parent or guardian, or by the parent or guardian on their own”. It examined the experience of inpatients or day patients, in acute and specialist hospitals in England, who were aged under 18. Again, over 90% of respondents rated the care they received as excellent, very good or good. Among the issues rated highly were: ● communication with staff was rated highly; ● the levels of confidence and trust of parents and children in staff ● their sense that they could discuss their worries and concerns ● information provided, at the time of discharge from hospital about what to expect, danger signals and medication. ● wards were generally felt to be safe and secure ● facilities for parents are good (but considerable variation between trusts in the quality of these facilities was reported). More problematic were the findings that: ● many children experienced delays at discharge. ● there was seen to be “scope to improve the explanations given about procedures and the risks, benefits and expected outcomes of treatments.” ● around a third of parents, and nearly half of young patients, wanted to be wanted to be more involved in decisions about care. ● facilities for adolescents and older children were not felt to be adequate 58%: of the young patients would have preferred to have been on an adolescent ward, and 16% on an adult ward. It will come as little surprise that compared with children, parents appeared to be more involved in decisions about care, and to be provided with more information. .
BOX 8 Key findings from the Primary Care Trust survey This was the second survey involving primary care trusts (PCTs) in England (the first was published in 2003). It concerns the experience of people using GPs and dentists. Among the most positive outcomes were: ● patients were highly satisfied with the amount of time they have in consultations with GPs, ● patients were highly satisfied with the care they receive from clinical staff. ● they reported being treated with dignity and respect and being listened to. ● they reported having confidence and trust in GPs, nurses and dentists ● they rated the service from reception staff positively rated. More problematic elements included: ● some patients had concerns about being overheard when talking to receptionists ● some patients also reported that they had not been told about how long they would have to wait to be seen. ● a fifth are of the smokers who would like help and advice to give up smoking are not receiving any. ● access to NHS dentistry is a well-known problem in the UK - two thirds of people who are not registered with an NHS dentist, said that they would like to be. It is also concluded that despite improvements since 2003, the 2004 data indicate that there is scope for better patient involvement in decisions about care and treatment. Decisions about medication and information about side effects were emphasised. Dental patients “report a decline in their involvement in care and the quality of explanations of treatment”. A possible sign of emerging problems is given by an increase in the proportion of patients reporting being deterred from going to the GP surgery because of inconvenient opening hours has increased (from 20% in 2003 to 22% in 2004). The survey also examined the issue of waiting for appointments, where there is a discrepancy between the reports from patients and official waiting time data. The latter indicates that 97% of patients can see a GP within two working days, In contrast the survey reports that only 54% of patients were obtaining GP appointments within two working days in 2004 (still, a marked improvement from the 31% in 2003).
BOX 9 Key findings from the Ambulance survey This was the first national survey of patients who have used urgent and emergency ambulance services. Many results were very positive: ● 98% of patients rated their overall care as excellent, very good or good ● patients reported very positive experiences across most aspects of care (e.g. that ambulance crews listened to them carefully and treated them with respect and dignity, that they had confidence and trust in the ambulance crews’ professional skills, etc.) There were some areas of substantial variation between ambulance trusts, which require attention from the low-performing trusts: ● the proportion of patients who received advice from the operator about what to do before the ambulance crew arrived (varies from 71% to 91%)’ and ● the proportion of patients who were taken to hospital (varies from 83% to 99%). Areas where the picture was less positive were that: ● just under one in five patients reported that ambulance staff could have done more to help control pain ● a fifth of patients reported that they did not fully understand the ambulance crew’s explanations of care and treatment (and were thus not able to consent to treatment from an adequate information base, and to be fully involved in decisions about care.
BOX 10 Key findings from the Mental Health survey This was the first national survey of the experiences of users of mental health services in England. It focused on the experience of people of working age who are ongoing users of mental health services. . More than half of respondents had actually been in contact with mental health services for more than five years. Social problems were prominent: for instance, only just over a fifth were in paid work. Nearly a third of service users were living alone. However, over a quarter were caring for children. The survey thus makes the case for health services to address the social as well as clinical needs of this group of patients. But nearly a third of people had not had help with finding accommodation, and more than half had not had help with finding work. (In contrast, more than two thirds of service users had received help with getting benefits.) As for clinical care, responses were broadly positive but quite mixed: ● over three quarters of service users rated the care they received as excellent, very good or good ● they were most positive about communication and relationships with clinical staff (such as being treated with dignity and respect, being listened to, and having confidence and trust in psychiatrists, nurses and other clinical staff) ● relationships with clinical staff were very important to service users. This was exemplified by open-ended comments from respondents. Also, there was a tendency for those service users who had greater continuity of contact with an individual psychiatrist to generate more positive responses. ● many service users wanted more involvement in decisions about their care and treatment - “decisions about medication, information about medication side effects, discussion of their diagnosis, understanding and involvement in care reviews and care planning, and understanding their rights under the Mental Health Act”. (Again, patients who do feel incompletely involved in decisions about their care and treatment, are often not able to meaningfully consent to treatment.) Some problematic areas were: ● less than a half of all service users (across all trusts – in some trusts the proportion was less than a quarter) had access to crisis care (such as an “out of hours” phone number of a mental health service worker). ● only a half of the service users had been given (or offered) a written or printed copy of their care plan, ● only a half of the service users had received at least one care review in the previous 12 months, ● finally, two fifths of respondents reported that they had at least one appointment cancelled or changed in the previous year.
Healthcare Commission – Very Recent Studies
During the preparation of the present essay, more recent survey results have been produced by the Healthcare Commission – and these have attracted some interesting press coverage, which we can also describe. Two national surveys, carried out in the autumn of 2004, asked patients across England about their experiences of emergency and outpatient departments. Results were published in the last full week of February 2005. The study of Emergency Departments27 followed in the wake of an earlier survey in 2003. (The same questions were used, and only statistically significant differences were reported as trends.) A postal questionnaire (with a covering letter) was sent to each of 850 randomly selected patients (aged 16 or over) who had attended the emergency departments (of each of the 153 acute NHS trusts in England that have such departments) during June, July or August 2004.28 Up to two reminders were sent to those who did not respond. A response rate of 44%29 - completed questionnaires from 55,339 patients, while 129,948 had been sent questionnaires – was achieved. Again the focus was on performance improvements, especially around such topics as waiting times, relationships and communication, and cleanliness, and the overall summary was that “Overall, patients report high and increasing levels of satisfaction with the care received in emergency departments, but there is still considerable scope to improve the information provided to patients.” Among the specific results: Since the survey of a year earlier, fewer patients reported visits to the emergency department lasted more than four hours; patients reported shorter waits at each stage of treatment in the emergency department. (It is not clear how far this is connected to innovations and/or procedural changes – but a substantial increase was noted in the proportion of patients receiving such tests as x-rays, scans or blood tests in the emergency department.) On arrival at the emergency department, 47% of patients had to wait no more than 15 minutes before they first spoke to a doctor or nurse, while 29% of patients had to wait between 16 and 30 minutes, 14% between 31 and 60 minutes, and 10% for over an hour. 90% of patients thought that the order in which they were seen was fair (a slight increase on the earlier survey). Where it came to actually being examined by a doctor or nurse practitioner, 75% of patients reported that this was within one hour, 22% of patients between one and four hours
Emergency department survey 2004/5, available at http://www.healthcarecommission.org.uk/NationalFindings/Surveys/PatientSurveys/fs/en? CONTENT_ID=4011238&chk=0bcNSV 28 People who attended minor injuries units and medical or surgical admissions units were excluded from the survey. 29 Taking into account a number of undelivered questionnaires and patients who had died in the meantime.
and 3% over four hours; 56% of those kept waiting were not told how long they would have to wait to be examined. Performance had improved on waiting time and information measures. There were smaller improvements in communication by staff, information provided to patients about their care and treatment, and patients’ satisfaction with the amount of time they had to see the doctor. The 2004 figures were that 66% of patients felt that they definitely had enough time to discuss their health or medical problem with the doctor or nurse, and 67% reported that they always got an explanation about their condition and treatment from a doctor or a nurse that they could understand (both figures show small improvements). 74% of patients felt that they had definitely been listened to by the doctors and nurses when they had something to say, and 51% of the respondents with anxieties and fears felt that they had been completely able to discuss these concerns (another 32% had discussed them to some extent). Patients continue to report high levels of confidence and trust in staff (73% had “complete” confidence) and to being treated with respect and dignity (but 11% felt that doctors and nurses had talked in front of them as if they were not there to some extent; 6% reported that this was definitely the case). 61% reported that all the staff treating and assessing them had introduced themselves, while 29% reported that this was the case for only some, very few or none of the staff. 77% of patients (considered that they were given the right amount of information. 7% claimed they were given no information. Under 1% thought that they were given “too much”. Fewer (of those capable) felt that they were involved in decisions about care to the extent wanted – 64% - in contrast 9% wanted to be more involved. Some 16% felt that they received conflicting information. Information provided to patients on discharge remains a concern, with a substantial proportion of patients leaving the emergency department without information about side effects of medicines, danger signals to look out for and when to resume normal activities. 85%) were given an explanation of how to take new medications and 81% received a complete explanation of the medication’s purpose – though 49% were not given an explanation of possible side effects. 63% were given at least some information on the danger signals to watch for following discharge, but 37% were not, and only 58% were told when they could resume normal activities. One third did not know whom to contact if they were worried about their condition after discharge. Patients’ perception of the cleanliness of emergency departments declined: at least in that fewer patients (45% - a 4% decrease) reported
that the emergency department was ‘very clean’. (The proportion of people reporting that the department was ‘not at all clean’ did not increase.) Cleanliness was picked up as a growing concern, in the openended comments as well. 69% of patients experienced pain while in the emergency department – when they requested pain relief medicine, 33% said that it took over 15 minutes to come (including 9% who did not get any). 84% felt staff did everything they could to help control pain, 16% did not.
The study of Outpatient Departments was released at the same time, and used broadly similar methods.30 It was carried out in all the169 acute NHS trusts in England with outpatient facilities (excluding maternity and psychiatric clinics); 850 patients aged 16 or over who had attended each outpatient department in June, July or August 2004 were sent a postal questionnaire and a covering letter. (Again, there were up to two reminders.) 143,596 patients were sent questionnaires, 84,280 completed questionnaires were returned, giving a response rate of 59% (excluding undelivered questionnaires and the death of some patients). We present some key results below following the headings used in the report: Before the appointment 17% of all respondents reported that they had to wait over three months for an appointment (an improvement on the 25% in 2003). 30% of patients reported that they were given a choice of appointment times, whereas 16% were not offered a choice but would have liked one. Waiting times had improved slightly, though only 20% were seen on time, or early and 21% had to wait 31 minutes or more. Cleanliness 53% of patients found the outpatient department very clean in 2004/2005, down from compared to 60% in 2003; and half found the toilets to be very clean, 5% less than 2003. Seeing professionals While slightly fewer people saw doctors, 75% of patients felt the time allocated was sufficient time to discuss their problems, and 3% felt they were not able to discuss them at all. 79% felt the doctor definitely listened to what they had to say (2% that he/she was not listening at al); 69% got answers from their doctor that they understood, (3% did not understand answers at all.) - slightly better than the results for patients who saw other healthcare professionals, Confidence and trust 81% of patients had complete confidence and trust in their doctors (3% reported no confidence or trust at all) and similar levels of
Outpatient department survey 2004/5 available at http://www.healthcarecommission.org.uk/assetRoot/04/01/48/71/04014871.pdf
As in other surveys, there is also data on how many patients report receiving consistent information from different members of staff ( 11% received either entirely or partially conflicting information); whether they were introduced to all examining and treating staff (23% were only introduced to some of the staff and 8% received no introductions); at all. Whether treatment was explained adequately (76% felt the doctor explained their treatment or action completely, and only 3% felt it was not explained at all; 80% felt the right amount of information was given to them about their treatment, 12% would have liked more information, 8% said they were not given any information at all); whether they were involved in decisions (70% felt that they were fully involved in decisions, 6% that they were not involved at all). Overall satisfaction ratings are also generated, with the majority of patients reporting high satisfaction levels with both the quality of their care and their experience within the department. In conclusion, we note the following statement: “The Healthcare Commission is continuing to develop the survey programme, particularly to improve response rates and develop more targeted methods to obtain the views of patients.” The publication of these two sets of results 9in February 2005 attracted some press coverage, which underlines the comments made earlier concerning the social and political significance of NHS surveys in the UK. For instance, The Guardian, under the headline “Lack of Information worries NHS Patients” (February 21, 2005 ) ran an article that generalised upwards from the survey data to point out that “Millions of NHS patients think doctors do not give them enough information to make sensible choices about how they want to be treated, the health inspectorate for England warned today.”31 Thus one of the more negative conclusions of the report has been highlighted for media coverage. Admittedly the article in question went on to report the positive news about shortening waiting times – alongside the negative views on cleanliness. Pointedly, given the emphasis on “choice” in current political debate about health (and education) in the UK, the article noted that patients were not asked whether they wanted choice about the place where they were treated – but the reporter did follow this up by pointing out that “many wanted more of a say about how they were treated once in hospital”. However, we note that in the survey of Outpatients departments, the issue of choice was actually addressed: The 2004/2005 survey sought to examine experiences connected with recent policy initiatives, and reported that 30% of these patients were offered a choice – not whether they wanted to be, to be sure, but not an irrelevant question! As
See the online version of the newspaper story at http://society.guardian.co.uk/nhsperformance/story/0,8150,1419071,00.html
always, it helps to examine the original source rather than relying on press reports! We shall skip the sections of the article detailing overall results, but go on to note that it highlighted evidence of one individual trust’s poor performance, and elicited responses from its managers:
“The trust with the worst rating was Newham University hospital in east London where 45% of patients said the A&E toilets were unclean…. the trust's chief executive, said it always passed cleanliness checks by outside inspectors. "My view is that the figures are not very accurate, but if it's what patients think, then it matters," she said… The commission said it was difficult to tell whether hospitals were becoming less clean or patients more alert to the problem after recent publicity about … hospital-acquired infections.”
A Union view was also solicited: “Dave Prentis, general secretary of the public service union Unison, said A&E departments were not going to get "very clean" status until more cleaners were employed.”
The Use of MORI work for Department of Health in Policy Formation
Returning to the theme introduced early in this paper – that the use of surveys as “evidence based policy intelligence” was itself an organisational innovation, it is relevant to consider how this topic is being conceptualised in (some) policy circles. A particularly interesting report discussing public attitudes to public services was produced in 2001 by the Performance and Innovation Unit (now the Strategy Unit) – this is part of the Cabinet Office.32 The report reviews studies of satisfaction with key public services, with a view to establishing the policy relevance of such data.33 In line with other studies of
Nick Donovan, Joanna Brown and Lisa Bellulo, 2001, Satisfaction with Public Services: A Discussion Paper; London, Performance and Innovation Unit 33 We confess a small stake in this debate, having rehearsed some of the issues in I Miles, 1985, Social Indicators for Human Development London, France Pinter. It is good to see them now discussed seriously in policy circles. The Strategy Unit report correctly notes that maximising satisfaction is not always an appropriate policy goal. Some socially beneficial actions may decrease immediate satisfaction (though increasing overall safety, for example); sometimes demand management may be in order. (We earlier speculated that satisfaction might be enhanced by various unethical and dubious means, as well – attacking enemies, supplying pharmaceuticals, etc.) But the case is made that satisfaction measures are relevant when it comes to aspects of services that involve face to face contact between users and service suppliers. Such measures, the Strategy Unit notes, may be used to Identify priorities for improvement; benchmark front line service “units” (such as hospitals), and as targets (for public
satisfaction, it is concluded that higher levels of satisfaction are associated with there being a good match between perceptions of the service received with expectations. It points out that expectations are formed by many factors – not just “the needs and characteristics of the service user” but also such factors as “previous experience, word of mouth, service reputation, the media, communications by the service provider… The role of the media is very important in forming people’s overall views of an institution such as the NHS.” A critical result of the study, with high relevance for policy discourse, was that: “Users of a service are almost always more satisfied than those who do not have first hand experience (for example, 80% of users of local secondary schools are very or fairly satisfied but only 30% of the general population are very or fairly satisfied with secondary schools.) Surveys of the general population which ask questions about satisfaction with, say, the NHS, are not useful guides to customer satisfaction and should be treated with caution.” This is a result that may also be of some import to social researchers seeking to use satisfaction and other “subjective” indicators in the course of analysis of innovation and other issues in health (and other) services. A great deal of data is reviewed in the report, though here we shall focus on health-related indicators, and how they are used. Among the results outlined here, then are: Studies of the proportion of users who are satisfied with selected local services: showed that most users are satisfied or fairly satisfied with these public services in most cases. The major exception is transport services, a longstanding source of complaint. However, the satisfaction with services of the general population is much lower. Less than 60% were fairly or very satisfied with the NHS (higher than the 39% and 30% fairly or very satisfied with primary and secondary schools, respectively). In the year 2000, 58%% of the public were satisfied with the NHS – as noted already, users 9those who had actually used health services in the last 12 months) were more satisfied than those who had not There were demographic differences - women and those aged over 65 tended to be more satisfied. (The report contrasts this with a British Medical association survey indicating that 47% of respondents thought that the NHS was “in much need of improvement”. Differences are also noted in
use or managerial purposes). All of these uses have been apparent in the NHS surveys reviewed earlier. There is also the question of how reliable and valid the statistical measures are: poor measures may “lead to the misallocation of resources and will be ineffective in increasing satisfaction”. The present author has not substantially changed his 1985 view that satisfaction measures represent a limited attempt to understand the emotional and quality of life aspects of our experiences as service clients and citizens. While not dealing with satisfaction indicators per se, it is also worth examining, in this context, the views of the British Medical Association concerning the dangers of a performance culture based on a narrow set 9and reading) of indicators: see http://www.bma.org.uk/ap.nsf/Content/measureper .
ratings of different professions, with a high satisfaction rating (90%) for GPs, a lower 52% for dentists. In cross-national comparisons (see Figures 2 and 3), satisfaction with health care systems varies considerably. In a 1996 Eurobarometer Survey of the EU-15; many Danes are extremely satisfied (90% were at least satisfied), UK, Irish, Greek and Portuguese are lower. The UK ranked 13th – 48% of respondents saying they were ‘very’ or ‘fairly’ satisfied. Italians were relatively dissatisfied - only 16% of respondents felt satisfied with the way their health system was run, and more than 75% supported major changes to the health system (the UK equivalent was still quite high, at 56%).These results do not seem to be just a matter of national propensity to complain – rather different patterns are picked up for satisfaction with the police Poles are reported to have “very low opinions of their police service and Americans high satisfaction ratings.” In the UK there is regional disparity, with high satisfaction in Scotland, England and Wales offset by Northern Irish views.) And a correlation of +0.57 was noted between levels of satisfaction in different countries and expenditure per capita on health. When asked who was responsible for the state of the NHS: 44% of respondents blamed the government, 16% NHS managers, and 2% doctors. The report suggests that overall satisfaction measures may be influenced by general attitudes to the government of the day. As evidence of media influence on satisfaction ratings, perhaps particularly amongst non-users, the case of the NHS anniversary is mentioned. In this week, the net satisfaction ratings of the NHS rose by 16%, probably reflecting the media coverage. The authors of the report also consider, on the basis of this example, that the volatility of such overall measures renders their use as performance targets rather dubious.
Figure 2 Satisfaction from health systems in the fifteen EU member states in 1996
source: Performance and Innovation Unit, 2001
Figure 3 Satisfaction with Health Systems
source: Performance and Innovation Unit, 2001
This essay has reviewed only a fraction of the large range of survey-based studies of the health services in the UK. The large-scale surveys described here are largely carried out for policy purposes. It is possible that more academic studies on a smaller scale will also have something to contribute to our understanding of the issues here. But what is apparent is that innovation and the culture of innovation is rarely a focus of concern. Many of the performance issues that are investigated are, of course, intimately related to innovation – many of these issues are the intended or unintended effects of technological or organisational innovation. It is to be hoped that in future work we may be able to interact more directly with those undertaking such surveys to build in more of an innovation focus into the analyses. The point has also been made that these surveys are not just quantitatively important, being among the largest survey studies conducted anywhere. They are also qualitatively important, representing something of a policy innovation in their own right. Surveys have become inputs to evidence-based policymaking in the health sector. This has rendered the process of conducting survey research in the NHS a politicised matter, and we have learned that it is very difficult to embark on such work without high-level sponsorship. Finally, we might anticipate that it would be possible to gain such sponsorship from a sufficiently well-formulated approach to stakeholders. For instance, at the end of February, a political debate emerged about the outsourcing – and indeed offshoring to Belgium, Spain and South Africa – for analysis by radiologists of MRI scans, from the NHS. The British Medical Association has complained of mistakes and delays in diagnoses, with doctors describing it as a "complete disaster". The Health secretary, John Reid, admitted "teething problems" with the contract, but blamed resistance to (certain forms of) innovation from professionals. (It was not clear whether the point was that professionals were refusing to trust valid analyses simply because they were from overseas, or that a lot more fuss was being made than was necessary.) In a radio interview he riposted: "Whenever we change from being entirely reliant on a monopoly of NHS provision and bring in extra capacity, which has been sitting there for generations domestically and internationally, from outside the NHS, we get resistance inside the NHS….But from the patient's point of view, the monopoly of the NHS has meant waiting lists for years that are now plummeting. It is hugely beneficial for patients."34
Having heard the radio interview, and failing to find any survey material bearing on the case, I refer you to the newspaper report of the affair at http://society.guardian.co.uk/nhsplan/story/0,7991,1423480,00.html
This suggests that studies of professional attitudes and practices may well cast light on what innovators generally describe as “obstacles to innovation” (though other stakeholders may see the issues at hand as more shaping of innovations or as quite rational practices). Survey studies into such themes could be extremely valuable.