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Frontiers of Health Report V9.Indd Social Research Institute Frontiers of performance in the NHS II “Stop looking up to the Department... and start looking out to your local populations and patients” David Nicholson NHS Chief Executive About Ipsos MORI Ipsos MORI is the sum total of two successful research companies, Ipsos UK and MORI, which joined together in October 2005 to create the second largest research company in the UK. We offer a full range of quantitative and qualitative research services, as well as extensive international research capacity. The Ipsos MORI Social Research Institute works closely with national government, local public services and the not-for-profit sector. We help policy makers understand what works in terms of service delivery, and we provide robust evidence to bridge the gulf between the public and politicians — we also provide a host of background information for clients on key policy challenges. The NHS and Public Health research team is a leading provider of research on attitudes of public service users, staff and other stakeholders. The team works extensively with the Department of Health and many Trusts and Strategic Health Authorities on a wide range of issues, from communications approaches to patient satisfaction, using the full range of research techniques. 2 Ipsos MORI: Frontiers of performance in the NHS II Contents Foreword 2 Executive Summary 4 Introduction 6 How is performance measured in the NHS? 6 Structure of the report 9 Part 1 – PCTs 11 1. What factors are associated with positive patient ratings of PCTs? 12 A. The effect of objective performance measures 12 B. Local population factors 16 C. Can we predict PCT patient ratings? 20 2. What performance levels should we expect? 24 A. Actual versus predicted ratings 24 B. Putting the patient ratings into context – who is performing well given their local conditions? 25 C. The best performers 26 D. Implications for PCTs 27 Part 2 – acute trusts 29 3. What factors are associated with inpatient ratings? 30 A. Perceptions of specific service dimensions and overall patient ratings 30 B. Local population factors 37 C. Can we predict inpatient ratings? 40 4. What performance levels should we expect? 44 A. Actual versus predicted ratings 44 B. Putting the patient ratings into context – who is performing well given their local conditions? 45 C. The best performers 46 D. Implications for acute trusts 48 Conclusions 51 What does this mean for you? 51 Appendices 53 Appendix A – Performance tables 54 Appendix B – Regression Analysis 90 Appendix C – Notes on the data 92 Ipsos MORI: Frontiers of performance in the NHS II 1 Foreword When we launched the preview draft of this report in January 2008, we were delighted with the response we received. The reaction from primary care and acute trusts alike has been that this report has given them important insights into how their patients view them, and, more importantly, what drives those perceptions. Perhaps the audience with the greatest interest in the report has been those health bodies faced with providing high quality services in some of the most challenging areas of the country. The report highlights the importance of “place” in shaping people’s views of the healthcare they receive: if you’re in a tough area, people are much less likely to give you the benefit of the doubt, and your satisfaction scores are likely to be lower than in the leafier, less deprived parts of the country. This is something many health bodies working in these tough areas have long suspected, and the report has proved an asset in starting to quantify this effect. The flipside is also true. Trusts and PCTs in less deprived, less diverse areas have an easier ride: their patients tend to be far more positive about the healthcare they receive. So a good patient score in these areas may simply reflect a more positive target population, rather than anything about the services per se. The message here for health bodies with high patient satisfaction scores is: make sure you’re not being complacent. Perhaps the key message from this is to reframe the question trusts and PCTs should be asking themselves. The question is not: how well are we doing? It’s: how well are we doing compared with what’s expected for this type of area? Refocusing the question in this way is key to helping health bodies consider more closely whether they need to raise their game. And as the following analyses show, asking the question in this way reveals some interesting shifts in who count as the better and poorer performers: the Newhams and Lambeths of this world are doing far better than their raw scores would suggest. For acute trusts, the analysis goes beyond this, revealing which of the things practitioners do are most linked to improved patient satisfaction. Privacy, pain control and good communication are all important – but the real drivers of satisfaction are treating people with dignity, involving them in the decisions that affect them, and making sure the place is clean. The question for trusts now is: what does this look like in practice? What specifically do you need to do to engender a sense of dignity – and how does this vary for different groups of patients? How involved do patients have to be to really feel involved in their healthcare decisions? What things really count in patients judging whether the wards are clean? Understanding these issues will be invaluable for acute trusts looking to build a stronger reputation amongst their patients. 2 Ipsos MORI: Frontiers of performance in the NHS II Perhaps the one gap in this analysis is understanding what PCTs can do to increase patient satisfaction. It’s a gap because the data we’ve been able to access for this report does not provide a ready route into this question. Nevertheless, it’s a question that PCTs should be focusing on. The World Class Commissioning agenda is driving PCTs to far better understand their local communities – and as part of this, it will be important to understand what’s driving your reputation and how satisfied people are with you. Comparisons on measures such as this are likely to become far more visible, so the best trusts would do well to really delve into this question. Historically, the NHS has not perhaps focused as much attention on social research as other sectors. We hope therefore that what follows demonstrates that it is worth paying attention to the research findings and what they mean. We hope too that you find this a useful contribution to the debate about how the NHS can best deliver the best patient care. Jonathan Nicholls Research Director – NHS and Public Health May 2008 Ipsos MORI: Frontiers of performance in the NHS II 3 Executive summary The NHS today increasingly talks about being “patient-centred”; its Chief Executive asks it to “stop looking up to the Department….and start looking out to your local populations and patients”. How well are those charged with delivery on the ground doing on this, and what factors affect patient perception? In 2004, Ipsos MORI published our first Frontiers of Performance in the NHS, exploring what was driving patient perception, and identifying key local factors that had very significant effects on patient perception. This report brings this work up to date, and raises a number of key questions. We explore those factors underlying the patient experience from a range of patient surveys – both individual aspects of the treatment and care received and more objective performance measures. We add to this with an examination of the geo-demographic factors that are associated with patient ratings – the nature of local population served by the Trusts in question – and ask what role local conditions play in determining patient ratings, as opposed to action by managers. The Primary Care Sector Our analysis shows again that objective performance measures, such as the standardised mortality ratios and expenditure per patient (reference costs), have little relationship with patient ratings of primary care services. Instead, the nature of local communities has far more impact. Our analysis shows that PCT services in areas with high ethnic fractionalisation (the extent of different ethnicities in an area), high deprivation, those with a younger population and those situated in London nearly always receive lower ratings of satisfaction than those serving wealthier, older, more homogenous populations. We can predict patient ratings with some accuracy, simply by knowing the characteristics of the local population served by the PCT. This means that when looking at patient perception of PCT services, it is important to take into account local factors: brilliance looks different in different places. Given the strong associations found, in some cases it will be misleading to consider just the raw scores of patient ratings in making judgements. Our analysis argues for a more comprehensive measurement of patient experience, taking all these factors into account. Lessons can be learned from those PCTs that are able to overcome the challenges posed by their local conditions and achieve relatively high patient ratings, like Lambeth. In this report we have analysed patient experience data for all PCTs and using regression analysis techniques, identified those Trusts which perform best and worst – after taking into account local conditions. The Acute Sector In the acute sector we find that the nature of the place has much less impact, although as with PCTs, and indeed ratings of the NHS by non-patients, London faces particular challenges, as do trusts serving younger, more ethnically fractionalised populations. 4 Ipsos MORI: Frontiers of performance in the NHS II As in 2004, for acute trusts, a limited number of individual aspects of care are highly correlated with overall patient experience.
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