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At the heart of general practice since 1960

Focus on...the patient feedback furore

He’s a GP just outside of Manchester, and according to the website, he’s a pretty good doctor.

By Steve Nowottny

He's a GP just outside of Manchester, and according to the website, he's a pretty good doctor.

In the past couple of months 21 patients have rated him – anonymously.

‘The nicest doctor I've ever met,' writes one. ‘Superb bedside manner,' raves another.

But there are two problems. One, the GP in question died in 2004. And two, he's Britain's most prolific serial killer.

The reviews of Dr Harold Shipman may be intended as black humour, but the website – US-based rateMDs.com - is no joke. In America, there are already dozens of sites enabling patients to anonymously praise or pan their doctor. RateMDs.com, launched in 2004, attracts nearly half a million visitors a month, with 600 to 1,000 posts every day.

Now it's our turn. A string of new measures, from both private companies and the Government, means GPs are to be scrutinised as never before.

Controversial new website www.iwantgreatcare.org, launched earlier this month, aims to replicate the success of rateMDs.com this side of the Atlantic, while the Department of Heath's NHS Choices website is to trial ratings at a practice level by the end of the year.

In the words of CMO Sir Liam Donaldson: ‘Patients should not be seen as passive recipients of healthcare interventions chosen and delivered by health professionals.'

Seeking patient feedback is nothing new: Florence Nightingale was championing outcomes measurement 150 years ago. But in recent years there has been an increasing emphasis on quantifying patient experience and satisfaction, through vehicles such as Government's Patient Experience Survey – now known as the GP Patient Access Survey.

The £11m annual survey, which delivered its first results a year ago, saw practices scoring highly but not, according to the DH, highly enough. While 84% of patients were content with their surgery's current opening hours, the 16% who weren't were used as a stick to beat GPs into providing extended opening.

Now, the survey is set to expand, with patients to be asked a broader range of questions from next year.

‘The questions will not just cover speed and convenience of seeing a GP, but also experiences when attending the practice such as its cleanliness or treatment by reception staff,' a DH spokesperson says. As Pulse revealed last October, the survey will become far more frequent, running every three months from 2010.

But health minister Lord Darzi's recent review of the NHS opens the door to even bolder moves down the road to patient power.

Patient Reported Outcome Measures – brief questionnaires asking patients about their condition, quality of life and how effective they think their treatment is – have already been used by BUPA and some independent sector treatment centres, and are now to be trialled in hospitals for hips, knees, hernias and varicose veins from next year.

They are intended to provide quality information about clinical services, allowing patients to make informed choices about where to go for care. But there are drawbacks. Achieving a meaningful response rate can be costly and bureaucratic and can't necessarily measure some of the more intangible benefits of holistic care.

But the Government seems keen to extend the idea to primary care, with Lord Darzi's primary and community care strategy promising to ‘explore the use of PROMs to enhance overall indicators of quality'.

Professor Alan Maynard, professor of health economics at the University of York, believes if they were to be included in the QOF, PROMs could bring real benefits.

‘We know with the QOF you get high achievement,' he says. ‘Maybe every time you go to your GP, you should fill in one of these questionnaires and then the GP has a time series of your mental and physical wellbeing.

‘When you as my GP send me off to get my hip done, you monitor the scores before and after recovery and make sure there is appropriate care where it is needed.'

The advantage of measuring outcome of a treatment rather than patient satisfaction is that it is more likely to reward good medicine.

Dr Toni Hazell, a GP in Tottenham, north London, says: ‘If I see a patient with dry skin who wants a referral to a dermatologist, I'll advise them to buy moisturiser over the counter and certainly won't refer them. The patient may not be happy, but if I referred everyone who wants to see a consultant and all other GPs did the same, the NHS would collapse in about 10 minutes.

‘Being a good doctor is not about doing everything that patients want.'

Unsurprisingly, rate-your-doctor websites are generally unpopular with doctors themselves.

RateMDs.com – which said it would take down the Dr Shipman review after being contacted by Pulse – is ‘hated' by most doctors in the US, its founder John Swapceinski freely admits.

‘There are some doctors who like the site,' he says. ‘But some doctors think we're just the spawn of Satan.'

‘We get threatened with law suits on pretty much a weekly basis,' he adds, although the site is well protected by US law and has yet to be successfully sued.

In Britain, the launch of www.iwantgreatcare.org earlier this month has attracted an avalanche of protest and a formal warning from the country's top libel lawyers, after it published anonymous comments branding named GPs as ‘arrogant' and ‘obnoxious'.

Dr Guru Singh, a GP from Loughborough in Leicestershire who was one of the 37 doctors behind the libel warning, believes the site is simply ‘another tool to keep bashing away at GPs'.

‘It's so unfair because people do not have any opportunity to reply to these sometimes unfounded allegations,' he says.

A recent poll of 1,050 doctors on doctors.net.uk – founded by the same doctor now heading up www.iwantgreatcare.org, Dr Neil Bacon – showed massive opposition to the project – with 11 respondents supportive, 11 neutral and 1,028 against.

But the site has received high-level backing from senior figures within the medical establishment, and is positioning itself to play a key role in the revalidation process. The GMC has refused to rule out use of anonymous patient comments in fitness-to-practise cases.

Dr Bacon acknowledges the site is in its infancy, and concedes improvements can be made in terms of monitoring users. Potentially libellous comments are now removed within hours of being put up.

But he remains absolutely convinced monitoring patient experience online is the future – and says PCTs, who have already expressed interest in buying aggregated feedback, agree.

‘If you want really huge numbers of patients involved, if you talk to trusts many of them are absolutely terrified about how they're going to do this,' he says. ‘In 2008 it's absolutely infeasible to suggest the internet isn't going to be involved in that.'

Dr Bacon has indicated his willingness to link in with wider Government initiatives on patient experience, and has even suggested the site could one day be integrated with NHS Choices.

But NHS Choices, which already allows patients to comment on hospitals, and plans to extend the service to primary care within months, has responded decidedly coolly to the overtures. It chose not to allow patients to rate individual doctors, and employs a team of 16 moderators to sift through any offensive or potentially defamatory material.

‘The virtue of the web is that it offers diversity but ultimately NHS Choices believes the public will want to place comments about NHS care on a website where they know they will be seen by the NHS,' a spokesman said.

The Picker Institute, a charity specialising in measuring patients' experiences of healthcare, lobbied hard to include patient feedback in the plans for revalidation announced this week, but has major doubts over it being provided by a site such as www.iwantgreatcare.org.

‘There is a science to developing questionnaire instruments,' says head of policy Don Redding. ‘It does need to be done with care and it can't be done on the cheap.'

But with increased scrutiny from patients inevitable, he warns GPs will have to embrace ‘proper feedback mechanisms' such as Patient Reported Outcome Measures - or face the consequences.

‘The day will come when it will be a choice for doctors – either play a full part in helping to develop the best quality of patient feedback mechanism, or be vulnerable to the fact that these other forms will be used.'

Patient power

Revalidation – ‘well-designed and carefully implemented patient questionnaires' to play key role in 360 degree feedback, with pilots to start next year

GP Patient Access Survey – formerly the patient experience survey, this is due to be ramped up with a wider range of questions next year and quarterly surveys from 2010

NHS Choices – official Government website currently allows patients to rate hospitals, with a pilot of GP practice ratings due to get underway by the end of the year

Other patient feedback websites – new website www.iwantgreatcare.org allows patients to rate their GP, following US-based rateMDs.com and hospital rating site patientopinion.org.

Patient Reported Outcome Measures – the ‘next big thing' in measuring patient experience, PROMs will be used in hospitals next year, with health minister Lord Darzi indicating he'd like to see them extended to primary care

FAQs: Patient feedback

Why is patient feedback the next big thing?

The Government is interested in patient feedback partly to help it monitor the quality of services, partly to help engage people with the NHS, but mostly to provide patients with the data they need to make informed choices. Like so much in the health service, it comes back to choice and competition.

What's planned for patient feedback?

The GP Patient Access Survey will be beefed up and NHS Choices' feedback facility will be extended to GPs, while the private sector is also getting in on the act, with the new websites like www.iwantgreatcare.org.

Aren't rate-your-GP websites libellous?

Potentially they could be – and libel lawyers Carter-Ruck have already sent www.iwantgreatcare.org a formal warning on behalf of 37 doctors. But supporters argue that feedback sites are already commonplace in other sectors, such as the travel industry, and safeguards are in place, with libellous comments being swiftly removed.

What are Patient Reported Outcome Measures?

Brief questionnaires that ask patients about their condition and quality of life, and allow longitudinal monitoring of patient experience and satisfaction. They will be trialled in hospitals next year and could be extended into primary care.

Patient power: how far should it go? Patient power: how far should it go?

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