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Are you being served?

Are you being served?

FEATURE | PATIENT EXPERIENCE
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The aviation industry is constantly being held up as ‘best in class’ in striking the difficult balance between providing excellent customer service and maintaining safety. This success is often referenced when discussing the NHS’s capacity to deliver a better patient experience and thanks to the government’s new mantra ‘no decision about me without me’. NHS organisations are now under more pressure than ever to follow this example, ensuring the ‘customer’ experience is at the heart of all patient exchanges.

At the launch of the first NHS Commissioning Board (NHS CB) mandate in November 2012, Health Secretary Jeremy Hunt said that it was his aim that a patient will be able to type in their postcode and see how the health services nearest them are performing. NHS Choices is currently in the throes of upgrading its GP rating programme to include a new raft of measures concerned with ‘patient experience’. Ratings will be based on responses from the GP patient survey and will score practices in England out of ten on measures such as communication, listening, convenience and waiting times.

Dr Neil Goulbourne, former GP and head of innovation at Virgin Care, says the NHS shouldn’t feel daunted by the task ahead in attempting to replicate the aviation industry’s customer-focused behaviour.

He notes airlines often face similar challenges to the NHS – the pressure to ensure safety is paramount while coping with critical operational issues being an example – yet they still manage to base everything they do around the customer experience. According to Dr Goulbourne, that is their “guiding light”.

“I do think it is possible for the NHS to replicate airline customer care but I do understand those who believe the notion is particularly unrealistic,” he says.
“Healthcare is in a very different financial position to the airline industry as patients don’t pay directly for the service, budgets are limited and in real terms are shrinking because of the growth in demand – but these are all used as excuses not to improve patient experience in the NHS.”

Despite Dr Goulbourne’s optimism, Dr James Kingsland, president of the National Association of Primary Care and the Department of Health’s clinical commissioning network lead, is uncomfortable about the use of the word ‘customer’ in place of the word ‘patient’. He argues that thinking of patients as ‘clients’, ‘buyers’ or ‘shoppers’ is “not the right way to go” and “devalues” what general practice should be aiming to achieve. He believes there should be a move to the idea that the clinician and patient are regarded as a “meeting of experts”, in which there is mutual respect and understanding.

While the customer service ethos is arguably part of the brand identity of Virgin companies, there is a general consensus that a culture change is needed to ensure this service-driven mentality is woven into the wider NHS. Katherine Murphy, chief executive of the Patients Association, says the NHS suffers from “institutional paternalism”, leaving patients often disengaged and disempowered from their care.

“Patients want to be seen much more as a whole person and not as a labelled person,” she says.

“They want their care to be personalised according to their individual needs, values and preferences.

“In order to radically shift clinician behaviour away from the traditional ‘doctor knows best’ relationship to a more customer-centred model – you need to have a huge shift in power and educate the patient that they can be seen as an equal and as someone who plays an important part in their care and treatment.”

Margaret Casely-Hayford, director of legal services and company secretary of John Lewis, was appointed a non-executive director of the NHS CB in June this year. Part of her remit is to bring customer-focused behaviour to the NHS and she is heartened by how the NHS objectives have evolved to focus more on giving leadership the space to foster a happy, collaborative and fulfilled workforce – something she claims is imperative to raising the quality of service in the NHS.

“When you begin thinking about the quality of service in an organisation, you have to also examine whether the people tasked with delivering the service are happy in their working environment. If staff members are unhappy, frustrated or unfulfilled, they will feel demeaned and their reactions will be tarnished.”

Continued customer feedback is helpful in terms of boosting staff morale and confidence in the instances where services are deemed ‘good’, Casely-Hayford says. Furthermore, as long as staff are used to processing feedback, she says in those cases where users identify poor performance or areas of improvement, critique will be well-received rather than falling on “stony ground” among “disaffected” and “disconnected” staff. The legal expert finds it difficult to predict whether the new patient feedback initiatives of the Friends and Family Test in hospitals and NHS Choices’ GP ratings will be “sufficient” in raising the general happiness of the NHS workforce, but says it is a “start” and provides a “platform from which to build on”.

Speaking at the Conservative party conference, held in Birmingham in early October 2012, Sir Stephen Bubb, chief executive of the Association of Chief Executives of Voluntary Organisations (ACEVO), called on GP surgeries to lead the charge on this revolutionary customer-focused culture change. But in order for this to happen, GPs need to look up and out of their practice window. Turning Point chief executive Lord Victor Adebowale was unequivocal about this at a Management in Practice conference in London and said GPs need to realise “they are not the centre of the universe”. Alex Massey, senior policy officer at ACEVO, thinks the customer service blockage comes from a lack of GP understanding over the range of innovative community and social offerings that are perhaps less focused on clinical interventions. It is this understanding of the agenda in prioritising the wants and needs of individual patients on the same plane as overall clinical outcomes at a statistical level that Virgin Care’s Dr Goulbourne predicts will unlock the cultural change needed.

It is also thought that the health reforms provide a platform for general practice staff to communicate with patients and “take responsibility” for the promotion of patients viewing themselves as customers as well as generally raising the overall care expectations of the NHS. While Murphy agrees about the opportunities the reforms will bring in this area, she claims there is a long way to go as the public are still as yet largely unaware of the changes the NHS is going through and are still in the dark about their increasingly strengthened rights with regard to their care in this new dawn of patient experience. Katy Pogson, associate director at healthcare PR agency Red Door Communications says that due to this lack of awareness, it is simply too early to judge how general practice communicates with patients as customers.

Nevertheless, she believes we are now at a “turning point”. Until now, she says, there just hasn’t been a need for practices to up their game in terms of good patient communication. But the increasing break from patients being viewed as a ‘captive audience’ means practices will have to devote time and money to expand their channels of communication like never before if they want to truly engage with their patients and deliver a good service.

“GPs need to be more holistic in their communication, not just in relying on letters and texts but thinking about using local media to spread the wider public health messages of the importance of seasonal vaccines and cervical screening,” says Pogson.

“As the NHS becomes more localised and competitive, GPs will have to focus on differentiating themselves from other practices in the area both on ease of access and on the communication channels they employ to ensure patient engagement.”

Put simply, the inaccessible, unengaged and unfriendly GP surgeries will see patient lists and practice revenue plummet in the new NHS unless they embrace alternative business models rooted in the wider context of patient experience. Department of Health-led pilots in six primary care trusts (PCTs) across London, Manchester and Nottingham are currently underway to test practice boundary abolition – further incentivising practices to up their game in terms of customer service. The pilots – which will now conclude in September 2013 – allow patients to register at a GP surgery near their work or attend as an out-of area patient. An independent evaluation of the pilots is expected to take place following the completion of the pilots to decide whether the policy should be rolled out nationally.

David Gilbert, director of inHealth Associates, also believes health professionals are going to need to be “pulled from the dark ages” in understanding the power of social media in healthcare. He claims clinicians are in danger of being “left behind” as thousands upon thousands of patients look to the web to provide peer-to-peer support on social networking sites such as Twitter and Facebook. Casely-Hayford says it is “odd” that healthcare hasn’t fully migrated online considering the increased access and confidence towards computers.

Business manager at The Ridge Medical Centre in Bradford, Nick Nurden is one person that is grabbing the opportunity to interact with his patients in new and innovative ways with gusto. Faced with costs of up to £20,000 for sending a single letter to all 25,000 patients on his list, Nurden is in the midst of building informal networks of patient mobile numbers and email addresses to widen his communication capacity. Add into the mix a wide and diverse patient population, with 40% from a south Asian background and 10% eastern European, Nurden’s team has also partnered with the local school and decided to go out into the community to educate and serve their patients directly. Something, he acknowledges, many practices will not have the luxury of being able to do.
“We have an increasing number of Slovakian patients who cannot read their own language thanks to their rural upbringing, so not only is it expensive to translate patient communication, it is also unnecessary at times,” says Nurden, who is also co-lead of the NHS Alliance’s Practice Manager Network.

“As the local school has the same problem in communicating with this
group, we sent our patient services manager along to the weekly groups the school had set up for Slovakian mothers to help them learn English.
“This contact allows them to talk directly to the patients to understand what issues they have in dealing with the NHS so we can make the service better for them.”

Despite this work in the community, Pogson criticised general practice on the whole for creating communication materials that mostly do not resonate with the majority of patients be it because they are far too technical, too long or not in the patient’s first language.

“If you are well educated and have good reading skills than the correspondence you receive from your GP is likely to fit the bill but it should not be one size fits all,” she warns.

“I would question how many GP surgeries, and how many healthcare providers in general, actually issue communication that is tailored to their audience.”

Casely-Hayford also offered a word of caution to those practices looking to offer online services to their patients, urging them ensure there is a “flexibility” in the service so as they do not forget about those “harder to reach” patients, such as those with Alzheimer’s, to ensure they do not feel ostracised by the progression in technology.

What is clear is patient experience is going to become an area of increasing importance as the NHS further opens its doors to the private sector. But with the likes of Virgin Care planning to introduce welcome packs and leaving packs with day-to-day essentials such as reading glasses to their ‘customers’ in their community hospitals to make it more of a ‘hotel experience’, can the public sector compete on the same scale? Virgin’s own Dr Goulbourne rejects the view that there is an unfair playing field between public and private sector providers. He says the contracts won by Virgin Care do not give the company “a licence to burn money”, rather the opposite is true - it generates savings year-on-year for commissioners of the service.

Gilbert says it depends what sort of substance and connectivity with other services such ‘welcome and leaving packs’ hold as to what success they will enjoy with clinicians and patients alike. He argues if the packs form part of a care package and signpost transition phases in treatment than they are likely to resonate with service users and clinicians. But he warns Virgin Care that patients are wise to those products that look “glitzy” from the outside but hold no real substance or relevance to their care.

John Lewis’ Casely-Hayford says rather than the playing field being uneven between public and private sector health providers, it is a different one. While the NHS may struggle to compete with Virgin Care’s ‘welcome and leaving packs’, she says private providers will have to contend with the NHS’ long lasting and ever familiar 64 year-old legacy. It is all about finding out what customers really value and hold dear when thinking about healthcare, she says.

“If you walk into lots of shops, there is music going on in the background and lots of frills and fiddle faddle. But John Lewis doesn’t have any of that and people still recognise the quality of the service. They are not there for the fiddle faddle, you just don’t need it in retail and you don’t need it in the NHS. You just need to demonstrate that you can deliver the goods with the right level of quality.”
Practice manager Nurden is optimistic about taking on the private sector in the arena of patient experience and is ready to take the lead from them in terms of consumer thinking.

“Patients have got a very simple agenda of what they want, but what they want and what they need is very different,” he says.

“It could be dangerous to give patients what they want,we have to stay focused in giving them what they need. We need to reeducate them on what is acceptable to want from the service. And once we do that we can compete with Virgin Care on offering a great customer experience.”

With this better education and new training structures for practice staff, Nurden says it is “entirely realistic” for the NHS to mirror the customer service of the aviation industry.

“I have just put my receptionists through some training on how to deal with aggressive patients and how to talk down patients who are angry. At the moment we are not particularly good at that because we have never needed that but suddenly receptionists have found themselves as the block to access to service and will continue to do that. We need to train our receptionists to make sure they do not end their conversations with patients after having a row but leaving them feeling as though they had got what they wanted.”

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