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Does the Friends and Family Test offer any tangible benefits to GPs?

Dr Emma Lees believes the test will boost morale amongst beleaguered practice staff. But Dr Tracey Vell argues that the introduction of the test erodes the core values of general practice

Dr Emma Lees


Last week I got my laptop fixed. A dashboard by the exit of the store flashed up three smiley-face buttons, with the words ‘How did you rate your customer experience today?’. I hit the green smiley face and left, feeling genuinely pleased that I had the opportunity to give positive feedback. Consumer evaluation is commonplace in the commercial world, but as much as I value patient satisfaction, I don’t want any smiley face buttons outside my consulting room.

The Friends and Family Test (FFT) can easily be seen as yet another irritating contractual requirement, but the optimist in me is searching for a silver lining. Most practices already exercise service improvement by reviewing complaints and feedback, through patient participation groups or with good old-fashioned comments boxes – surely this isn’t so different.

Compared to other contractual requirements, doing the FFT, is relatively low-effort. There is no minimum threshold for the number of completed tests submitted and no punitive measures for those performing less well. Practices are provided with the opportunity to take note of the feedback and try to improve.

The real value of the test, however, seems to be in the free-text box that follows, where patients can make suggestions or voice complaints. Feedback collected from the test is a more accurate reflection of quality than some other measures such as a CQC inspection. Practices are urged to reach out to the full spectrum of their population, which should give a more inclusive measure of our work than traditional methods measure.

In addition, despite the relentlessly negative portrayal of our profession in the media, most patients value and appreciate their GPs and this positive feedback may well boost morale among practice staff.

It may also become the impetus for change that matters more. Since it was launched in inpatient and A&E departments last April 2013, lots of cheap and simple ideas suggested by patients in the free text section of the test (such as having Marmite on the breakfast trolley or soft-close bins on wards to reduce noise at night) have made dozens of hospitals better.

And whether we like it or not, the test will soon be upon us. It could be worse: at least there are no smiley-face buttons involved.

Dr Emma Lees is an honorary clinical research fellow at Imperial College London and a GP registrar in Surbiton.


Dr Tracey Vell 330x330 online


The requirement for us to do the Friends and Family Test lacks evidence, needs a revised format and will be unhelpful to both patient and GP.

Since the FFT went live in April 2013, it has had no statistical significance and is merely an opinion of a user at a particular point in time. Yet we are told it will assist decision-making about services in a practice.

The question itself is totally unreasonable. How likely are you to recommend our GP practice to friends and family if they needed similar care or treatment? commands possible answers including ‘Extremely likely’ and five other options. But GPs know as well as anyone thatsome parts of the population will never answer ‘extremely’ anything. It is weighted so that three negative answers count against you.

Patients currently have much more effective pathways to share their opinion via PPG, dialogue with practices, Healthwatch, local CCGs and boards where they are represented. 

The publication of results of poor-quality monitoring processes does disservice to the general public. We also see the un-vetted personal opinions of patients displayed on NHS Choices and they serve to remind me of the conflict of patient want and demand.

But perhaps the most important problem with it, is that it sits at the heart of the conflict between opinion and evidence. For many years, GPs have tactfully fulfilled gate-keeping roles and patient relationships have been maintained. But there is now a pendulum swing, due in one part to the Government unleashing the desire to yield to patient want.

GPs are increasingly pressed to avoid unnecessary admissions, to take on more work and be more accessible. In these daily situations we know we balance demands of the patient and their increasing abilities to complain against the needs of the evidence. But a weighted ‘evidence’ of public opinion against the practice, however small in numbers, will have its voice heard.

The FFT offers no tangible benefit to GPs, and having a decision of ‘Extremely Likely’ or ‘Likely’ dictating the future of a practice has bound us on a path of destruction. Can we hold on to the principles of our practice or should we now consider a smiling mediocrity? Surrender our job satisfaction for job security?

These decisions are set to destroy the health economy as they lead us down a path of patient want, leading to increased referral, investigation and prescribing.

Dr Tracey Vell is the honorary secretary of Manchester LMC and a GP in Rushholme.

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Readers' comments (22)

  • you would think a 'research fellow' might want to look at the evidence for spending scarce resources on this and judging this against clinical benefits.

    Even in hospital no-one has tried to suggest there is any evidence of benefit.

    This whole exercise is so NHSE can say its doing something that sounds like a metric for its meetings with government.

    Real evidence is difficult and comes up with the wrong answers!

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  • Emmas scenario - We have fixed your laptop = Three smiley faces. My patients scenario - I cant treat your fungal toe nails because the CCG is currently £2m in deficit and local guidelines now refuse to allow me to treat it = No smiley faces. I will refer you for counselling but the current waiting list is 12 weeks = no smiley faces. We get judged on what we are allowed to offer which is not in anyway comparable with your laptop repair.

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  • I'm afraid that Dr Vell's attitude demonstrates some of the failings of primary health care. FFT clearly has shortcomings but it at least tries to reflect the views of the patient and taxpayer about a service which is, in some areas, falling behind what people now generally expect. The issue of the use made of the results by NHSE is a different matter but we have to improve/increase the collection of patient views/experience.

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  • Anonymous | NHS Manager | 01 December 2014 11:33am

    Failings of primary care? more like unreasonable expectations of the populace. see above entry re fungal toe nails. as well as above entry about REAL evidence, not subjective b*llshit

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  • FFT is not helpful. A patient survey already exists and I have had nearly always positive results. The less positive ones with comments has helped me 'improve.' The completely negative 'he ain't a proper doctor he gave me no antibiotics' should have gone in the bin; had it read he didn't explain to me why I didn't need treatment may have been appropriate feedback, but there are patients who despite using words of one syllable will never be happy if there expectation is not filled. After all instant access to a family bucket of chicken is cheap and requires no effort of forethought or washing up.

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  • Dr Vell has the wrong end of the stick about how the results will be presented to the public. All the positive ratings - whether likely or extremely likely - count together towards a positive result, as is the case with the negative ones. It must be good to be a GP practice without room for improvement and not need patient feedback to prompt you to do things better, Dr Vell. You are clearly a person who likes to be able to express your dissatisfaction - in this case with the FFT - so why would you want to deny your patients the opportunity other than in a once-a-year survey? You might just learn a thing or two.

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  • Yes, in theory a proven and well balanced feedback system would provide a useful tool for any area. Not just GPs.

    However FFT just like CQC and many others are completely unproven and get lost in bureaucratic nonsense. The thought that "doing something" is better than "doing nothing" inevitably leads to the laws of inintended consequences

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  • The worry is that the FFT may actually do harm because it is not scientifically structured to be a representative sample of a practice list. Biased information is well known to damage patient care because it targets resources away from areas of real need towards those that respond loudest such as commuters and the minority of inappropriate service users. This is not a scientifically validated survey method and therefore not something doctors should associate themselves with.

    By using prejudicial data, the wishes of well but vocal patients, are likely to ride roughshod over the needs of patients who have palliative needs but are too ill to participate, those who have learning disabilities that are severe enough to cause communication problems, those who are chronically frail, housebound or suffering from serious disease and a variety of other minority groups.

    The FFT is unethical because it cannot guarantee equitable and fair representation. It is likely to promote bad practice because it introduces perverse incentives into the system such as excessive antibiotic prescribing. It's advocate really should know better and this pseudo-science should be abandoned immediately.

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  • Surely any criticism arising from patients who want antibiotics that you don't prescribe is to do more to educate your patients about WHY you don't prescribe them in unsuitable circumstances. The feedback tells you where you have a problem, such as patients misunderstanding things, and gives you the opportunity to address that. Why be defensive about it? Some of these comments give the impression that a small minority of GPs regard their patients as way beneath them. You run small businesses and these people are your customers. Show them some respect, please.

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  • @4:52 the customer is always right mentality does not apply in healthcare. NHS staff always shows respect to patients but you assume that those giving feedback are correct 100% of the time. the data is pseudoscience and will lead to adverse outcomes. people will prescribe abx to avoid poor feedback scores. GPs are restricted in what they do. you cannot offer everyone a scan and everyone the latest drug that they want. scans and drugs are rationed and that will never be acceptable to someone coming to you with a customer like mentality.

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