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Perceptions of quality in NHS secondary care A research report for NHS West Midlands

July 2010


Contents Foreword ......................................................................................... i Glossary ........................................................................................ iv Executive summary ....................................................................... 2 1. Introduction .............................................................................. 16 2. Defining excellent care ............................................................ 26 2.1 Making judgements about quality in secondary care ................... 28 2.2 Patient focus: empathy, respect and communication .................. 28 2.3 Waiting times .................................................................................... 31 2.4 Hospital environment and facilities ................................................ 33 2.5 Clinical treatment and standards .................................................... 35 2.6 Summary ........................................................................................... 37

3. Views on dimensions of quality in local secondary care ‌‌40 3.1 Patient focus..................................................................................... 41 3.2 Interactions between patients and hospital staff .......................... 46 3.3 Hospital communication and coordination .................................... 50 3.4 Waiting times .................................................................................... 54 3.5 Hospital environment and facilities ................................................ 57 3.6 Clinical treatment and standards .................................................... 60

4. Perceived barriers to providing excellent care ...................... 66 4.1 Resources and staffing.................................................................... 66 4.2 Effective and visible management .................................................. 70 4.3 Communication and involvement ................................................... 71 4.4 Other barriers ................................................................................... 73

5. Quality at the heart of the NHS ................................................ 76 5.1 Perceived priorities of the NHS ....................................................... 77 5.2 Reassuring people that quality is the top priority ......................... 88


6. Accountability ........................................................................ 100 6.1 Awareness of systems & procedures .......................................... 100 6.2 Apologising for lower than expected standards ......................... 103 6.3 Providing a clear complaints procedure ...................................... 104 6.4 Feeding back .................................................................................. 106

7. Information provision ............................................................ 110 7.1 Sources of information about quality of care .............................. 111 7.2 Information requirements of patients and the public.................. 119 7.3 Information requirements of staff ................................................. 122

Appendices................................................................................. 126 1. Statistical reliability 2. Definition of social grades 3. Logistic regression 4. Public perceptions around cleanliness in hospitals 5. Planned care patient experiences


FOREWORD In High Quality Care for All, Lord Darzi, the then Health Minister, set out his vision to make quality the organising principle of the NHS. Quality accounts, CQUIN schemes and Quality Observatories were three specific initiatives that were introduced to secure this vision. The new coalition government has strengthened this commitment to quality by making patient outcomes and experience the key measures of success for the health service. But what is it that drives patients’ experience and perceptions of quality? Drawing directly on qualitative and quantitative research carried out in the West Midlands, this report aims to enhance our understanding of what matters to people when they think about high quality NHS hospital care. The report compares and contrasts the factors that influence the perceptions of patients, staff, visitors and the public around quality. All groups recognise the multidimensional nature of quality. Patients, for example base their views about the quality of a hospital not only on the care they receive but also on how they see other patients being treated. The way in which visitors to hospitals are welcomed or not on arrival at the ward where their loved ones are being cared for is clearly a significant proxy for judging overall quality in the minds of many people. Where patients can’t see what they understand as tangible signs of leadership or governance on wards this gives rise to anxieties about quality and accountability. Staff and patients hold different perspectives on clinical outcomes. For patients, who have only limited means of assessing clinical practice, good clinical outcomes are expected as a minimum. Staff have a more detailed and rounded views of clinical outcomes. The findings emphasise the importance of communication with patients and between clinicians as crucial to the delivery of high quality care. The report demonstrates a need for more meaningful and relevant information about quality for staff, patients and the public. Many patients are more likely to reach views about the quality of local hospitals based on media reports than on information published by the NHS. Staff have a real appetite for comparative information about the quality of the services they deliver, but the majority rarely see such information. This agenda will need to be taken forward by Trusts and Commissioners, in partnership with other organisations such as the West Midlands Quality Observatory (WMQI). All NHS organisations are facing the challenges resulting from a growing and ageing population, the introduction of new technologies and treatments, alongside the need to ensure that we are achieving best value from the available resources. This report will help to identify priorities for ensuring that high quality care is delivered, and that the perceptions of different groups are taken into account. This report is being circulated to all NHS hospitals and PCTs across the region. Trusts and commissioners will need to consider the findings of the report alongside other survey data and evidence, to enhance experiences and perceptions of quality. This report should be used to guide the selection of indicators in NHS Trusts’ quality reports, the design of CQUIN schemes and to influence the agenda and work programme of the new West Midlands Quality Observatory. Moreover, we hope that the findings will help NHS Trusts and commissioners of these services to ensure that attempts to improve quality are grounded in what is important to the people who use them. NHS West Midlands

i


Glossary

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Glossary This glossary gives definitions of the terminology we have used throughout the report.

Patient – Throughout this report, “patient” is used to refer to those who say they have been an inpatient or outpatient in an NHS hospital in the last year or so.

Public – Throughout this report, “general public” is used to refer to those who say they have not been an inpatient or outpatient in an NHS hospital in the last year or so.

Visitor - Throughout this report, “visitor” is used to refer to those who say they have visited someone in an NHS hospital in the last year or so.

Trust – Hospital Trusts, or Acute Trusts, are organisations that provide secondary healthcare services. A Hospital Trust may include one or more hospitals.

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Executive summary

1 Š 2010 Ipsos MORI.


Executive summary With a renewed focus on quality, the NHS is striving to deliver safe and effective care, provide an excellent patient experience, whilst achieving the best value from NHS resources. This research was commissioned as a foundation for future developments relating to the quality of secondary healthcare, to ensure that steps taken reflect the concerns and priorities of staff, patients and the public in the West Midlands. The aim of the research was to carry out a robust and challenging investigation into how patients, the public and staff think about quality in relation to secondary care, their views on the quality of hospital services, and how they expect excellent care to be delivered. Following a detailed analysis of the literature pertaining to the perceptions of quality in healthcare, a series of discussion groups were undertaken with staff, patients and the public to explore their views and experiences on a variety of relevant themes. The findings of the qualitative research fed into and were tested by a representative survey of residents across the region, and a large-scale survey of staff across seven hospital Trusts.

1. Key findings 1.1 How do patients, the public and staff think about quality in hospitals? The participants in the discussion groups emphasised that the way they think about quality in a hospital environment is different to how they think about quality in other parts of their lives, due to the emotional impact of being in a hospital and associated feelings of vulnerability. This meant that they had much higher expectations of the care they should receive and things that might go unnoticed in other situations (e.g. someone smiling at them) took on a greater significance. In the discussion groups participants thought about what a good quality experience in a hospital would be like and what factors were important in this. Many different dimensions were identified as important, as is shown in the diagram below. The aspects in the top right box are important to patients, the public and staff, while those in the top left are important to patients and the public, and those in the bottom right are important to staff.

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Dimensions of quality identified in the qualitative research

Importance for patients and public

Waiting times when at the hospital

Treating patients as individuals

Affordable and appropriate parking

Spending time with patients

Dedicated smoking area away from the hospital entrance

Explaining treatment to patients Involving patients in decisions

Reducing anxiety Cleanliness Good quality food Well-managed visiting hours

Timely discharge Single-sex ward Internal communication Quality of equipment Quality of clinical treatment (taken as a given for public & patients)

Importance for staff

Treating patients as individuals was a strong theme through all of the groups and was seen to underpin all of the other areas seen as contributing to excellent care. It involved staff having time to spend with patients talking about their treatment and helping patients to feel involved in decisions about their care. It also included the way staff interact with patients, with a particular emphasis on the need for staff to be warm, friendly and approachable. Patients also mentioned that the ways in which they saw other patients being treated would have an impact on their views, particularly patients they perceived to be vulnerable. When you walk into a hospital, you want to be greeted by somebody who is going to listen to what, why you’re there, and then tell you to go to the appropriate place to get the treatment that you need for the reason that you’re there. And then when you’re directed to where you should be, again, you want to be greeted and treated. Female, Under 35, General Public …….That’s quality to me, looking after your patient, making sure they’re comfortable, they are happy in their environment. Staff member

Patients and the general public tended to put less emphasis on clinical outcomes and treatment than members of staff. This was partly because they found it difficult to judge how

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good or poor their treatment was, but they also simply expected there to be a good outcome from their care. For clinical staff particularly a good medical outcome was seen as central to their thinking about quality. I think if you see a consultant, you take it for granted that they’re at the top of their game. Female, 18-34, Patient I think if you look at what clinicians think good quality of care its outcome data and it’s, by outcome I mean that the patient survives, the patient does well, everything was successful as far as clinical results are concerned and that the patient is happy with the interaction they’ve had with medical and paramedical staff. Staff member

1.2 Views on dimensions of quality in local hospitals The findings from the discussion groups fed into a quantitative survey of staff, patients and the public aiming to analyse local perceptions around the various dimensions of quality in more detail. The results from the survey demonstrate that patients, the general public and staff are generally positive about most aspects of care provided by their local Trusts. Satisfaction with clinical treatment, the outcome of care and the way and manner in which staff deal with patients – such as being friendly, polite and professional – are all fairly high, with positive perceptions amongst the majority of all three groups. There are also aspects which were highlighted as areas for improvement. Perhaps the most important of these, given its prime role in influencing perceptions of excellent quality of care, is increasing the amount of time staff have to spend with patients. Patients, public and staff also all raise aspects of communication and coordination, both within the hospital and between the hospital and the GP, as areas where they are relatively less satisfied. It is interesting that residents who have visited friends or relatives in hospital are significantly less positive about most of the aspects of quality asked about than those who have been patients. This suggests that the good quality care experienced by patients is not recognised by visitors while they are in the hospital, and more might be done to ensure that visitors‟ have an appropriate understanding of the care being provided.

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1.3 Quality at the heart of the NHS The majority of patients, the public and staff feel that their hospital does place quality of care as their top priority, with many staff feeling that it has actually become a greater priority over the last two years. However, patients and the general public, as well as clinical staff sometimes feel that financial resources and government targets are more important to senior management, than quality. This perceived discrepancy between frontline medical staff and senior hospital management, with the latter less commonly thought to prioritise quality, appears to be a key driver of opinions on quality. Regression analysis was carried out to determine whether there were any associations between respondentsâ€&#x; opinions on whether quality is their hospitalâ€&#x;s top priority and their views on the different dimensions of quality. For all groups, perceptions about whether the hospital delivers safe medical care, minimises pain, and whether there is effective communication and co-ordination are important drivers of their views on quality. The results in the table below identify factors associated with high odds of agreeing that their Trust places high quality care as its top priority. The results should not be interpreted as indicating a causal link, as we could not say that any of these factors cause someone to think that quality is prioritised, but that there is a strong association between the two.

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What drives perceptions of quality in secondary care? Patients – are more

Visitors – are more

General public - are more

Staff - are more likely to

likely to think that their

likely to think that their

likely to think that their

think that their local

local hospital places

local hospital places

local hospital places

hospital places quality

quality as its top

quality as its top priority

quality as its top priority

as its top priority if

priority if they….

if they….

if they….

they….

Agree that their local

Agree that hospital nurses

Work in the NHS

Are satisfied with the

NHS hospital provides

have quality of care as

safe medical care to

their top priority

overall quality of care

patients and minimises pain; Have attended hospital as an outpatient

overall quality of care Are satisfied with the

Agree that their local NHS

provided by their local

hospital provides

hospital

managers have high Agree that their local NHS

patients;

hospital provides safe Are satisfied with the

cleanliness of the hospital

overall quality of care

environment

priority Agree that everyone in

Are satisfied with the

provided by their local

aftercare patients receive

hospital

after treatment

the organisation actively contributes to good quality patient care

Are satisfied with patients receiving a good outcome

Agree that how they see

quality of care as their top

medical care for patients;

Are satisfied with waiting times

hospital Agree that senior

minimises pain for

Are satisfied with the

provided by their local

Are satisfied with the friendliness of staff

from their care

other patients being Agree that senior

treated affects their

Are satisfied with the

perceptions

amount of involvement of

managers have high quality of care as their top priority

patients in their care Are satisfied with the friendliness of staff

Agree that patients feel in

Are satisfied with communication between

control of their care Are satisfied with the co-

hospitals and GPs

ordination of care between departments and wards For further detail see chapter 5.

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2.0 Reassuring people that quality is the top priority - key challenges In the discussion groups patients and the public were asked what would help to reassure people that quality was at the heart of the work of their local hospital. They were then asked to identify some practical steps which a hospital might take to improve perceptions. These suggestions were then tested out in the quantitative survey. Although many findings from the research are positive, in this section we focus on areas which are challenges for the NHS in terms of reassuring staff, patients and the public that quality is the top priority.

2.1 Perceptions of staffing levels When the discussion group participants were asked what would reassure them that excellent care was the priority in their local hospital, seeing more nurses on the wards was the most common answer. The perception that hospitals are short-staffed wound through many discussions and was highlighted as a key area of concern in the survey with the general public and patients. This contrasts with actual staffing data which demonstrate an increase in staffing levels overall. Data from the NHS information centre demonstrates that there has been a 24.5% increase in nursing staffing levels between1998 and 20081. Clearly, patients and the public are unlikely to have access to detailed information on staffing levels. The sections below try to explore what is driving this perception. In the residentsâ€&#x; survey, the main reason given by those who felt that their hospital did not have enough staff, was that staff looked busy (46%). Similarly, patients and the public in the discussion groups reported that staff looked too busy to talk to them. Group participants also referred to comments made by staff about under-staffing. A further underlying reason for perceiving a staff shortage is the waiting times while at the hospital, which can give the impression that there are not enough staff in the ward to attend patients. In the survey, this was the third highest reason given by those who believed that their local hospital was understaffed (12%). The research shows that many people are willing to accept a wait if they are warned in advance and receive an explanation for it (from any member of staff, not just doctors). However, if patients do not understand why they are waiting, they are likely to assume that this reflects staffing issues.

1

http://www.ic.nhs.uk/statistics-and-data-collections/workforce/nhs-staff-numbers/nhs-staff-1998-2008-overview. Includes all qualified nurses including practice nurses.

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Having sufficient time dedicated to patient care was also a concern for staff. In the discussion groups with staff, mention was made of pressures on staff time and the impact this had on patient care. In the quantitative survey, staff highlighted issues around the amount of time that they are able to spend with patients as a key priority for improvement. Some staff mentioned actions they could take themselves to spend a greater proportion of their time with patients. They also highlighted several aspects which they felt the Trust could do to help them free-up some of their time – by reducing the number of non-appropriate or bureaucratic tasks they have to do, and instead dedicating this time directly to focusing on patients.

2.2 Clear, visible leadership The results of the quantitative survey show that staff place particular importance on having good communication within the ward or department, as well as also highlighting the importance of leadership right through the hospital. Some staff in the discussion groups thought that wards with better management seemed to run better, even when there were staffing issues. Patients and the public identified clearer and more visible leadership as a way of improving their image of the organisation of hospitals and this was something linked directly to improved perceptions around quality of care in the quantitative survey. Awareness of current ward management structures was low and there was a perceived lack of accountability at ward level.

2.3 Communication and coordination The effectiveness of communication within wards or departments, as well as between wards and departments, was identified as a key driver of perceptions of quality. The main concern was improving lines of communication, so there is more “joined-up” care within the hospital. This ranges from good handovers between shifts or clinicians, to wards being aware of when their patients are due at another department for tests. Sometimes patients reported that they were not clear who was in control of their care across the hospital. Aftercare was also highlighted as an area for improvement in terms of communication. Communication with patients is also very important in making them feel comfortable and reducing their anxiety – key to their perceptions of excellent care. Patients felt that it was essential that clinicians carefully explained treatment to them so they were fully aware of what was going to happen. This also included communication with families of more vulnerable patients. Welcome packs were suggested as a way of explaining to inpatients

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what they can expect while on the ward. These may save staff time as they would only need to highlight key points for patients who they were confident would be able to read and understand the pack. Improving communication between frontline managers and staff within the hospital was a key priority for staff. A concern that emerged within the staff survey and discussion groups was that managers were not fully aware of the day-to-day realities of working on the front-line. This was coupled with a perception that managers were sometimes more focussed on government targets and initiatives and less concerned with patient care. Staff welcomed managers spending time with front-line staff on a day-to-day basis – not necessarily as occasional visits that wards prepare for, but with the aim of understanding the difficulties that staff face daily. Front-line staff also felt that they could be involved more in decisions, such as the best equipment to purchase.

2.4 Demonstrating accountability Two key drivers of views on quality – providing safe care and minimising pain – relate to the quality of clinical treatment. The overwhelming feeling is that hospitals currently perform well on these aspects in general, but they could do more to better inform people of the systems and procedures they already have in place to ensure safe care – including complaints procedures. Similarly, collecting feedback from patients and staff, and then being seen to act on that feedback helps to improve perceptions of quality. The research reveals that although people are aware of feedback being collected, there is a perceived need for improvement around what is done with the feedback and how resulting actions are communicated back. There were indications that some patients do not feel comfortable enough to give honest feedback. Patients in the discussion groups expressed some fear around giving negative feedback and were concerned that it would impact on their treatment.

2.5 Improving the hospital environment With cleanliness as a key driver of perceptions of quality, the research emphasises the importance of making sure that cleaning practices are visible, with a clear schedule showing how frequently areas have been cleaned. Lack of clarity about accountability for cleaning was also a common theme. Patients in the focus groups felt that they did not know who was taking responsibility for cleanliness at the ward level. In addition, they did not feel comfortable to report concerns around cleanliness.

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3.0 Information provision around quality The research demonstrates an appetite for relevant information about quality amongst staff and the public. The survey found that around two in five staff had not seen any information, within the last three months or so, on the quality of care provided by their team or ward (43%). Only more senior and clinical staff who took part in the discussion groups regularly accessed information about quality of care. Little of this information actually compared performance with other organisations outside the hospital. Fewer than 10% of staff had seen information comparing quality of care with others outside their own Trust. Those who had seen information reported that this was mainly about patient experience, staff training and adverse events, and generally found it useful. The research suggests that there is a desire to access information on quality amongst staff but that this information needs to be relevant (linked to their own or their ward‟s performance), timely and easy to access and interpret – generally hard copies are preferred by staff who do not regularly use a computer as part of their day-to-day role. Patients and the public in the discussion groups tended to get information about their local hospital and its priorities from the local media (e.g. local newspapers or regional television news) and via word of mouth in the local community. Although patients tended to be positive about the overall quality of care they had received from their hospital, their perceptions of the hospital as a whole were often still affected by negative press and word of mouth. Almost without exception in the discussion groups, the information participants had heard from others and the media tended to be negative, and this is corroborated by the survey, where approaching half say the things they hear about their local hospital from other people and through the media are generally negative. Despite this, the majority of those who say the things they hear are generally negative would still choose to go to their local hospital – locality seems more important than negative reports, with only 22% of people saying they would go elsewhere. In terms of the information that patients and public would like to see on quality, information on waits while at the hospital, information on hospital infection rates and information on the systems and procedures in place in the hospital to follow-up when things don‟t go as planned are some of the more practical aspects identified. However, in the discussion groups, participants admitted they were unlikely to seek out this information unless they were going to be a patient. Hence, people want information that is easy to understand, relevant to their needs and in places they can easily access when they need it.

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4.0 Points for further consideration by Trusts This section sets out key findings from the research that secondary care providers might consider in order to improve perceptions of quality amongst patients, visitors, staff and the general public.

4.1 Improving internal communication and staff involvement in decisionmaking The findings demonstrate that the overwhelming majority of staff are motivated by the work they do and providing excellent care, but over a third feel that there needs to be better communication and involvement of staff in decision making (40%). Greater visibility of managers on the frontline and listening to staff, is also felt to be important.

4.2 Maximising the time staff have available to spend with patients A recurrent concern in the work with patients and the public is the perception that there are staffing problems in hospitals. This is driven by the observed numbers of staff on wards and the time that staff appear to have available to spend with patients. Staff themselves feel that they would like to have more time to devote to talking to patients. Many members of staff highlighted that wards which were well managed were better able to deliver patient focussed care, even when there were problems around staffing. Initiatives such as „Releasing Time to Care: the Productive Ward‟ might help in this regard.2

4.3 Improving the focus on person-centred care The research demonstrates that patients and members of the public tend to make different judgements about quality in the hospital environment compared with other places they visit as part of their daily lives. The participants in the focus groups emphasised that their emotions are heightened when they are in a hospital environment and this means that things that might go unnoticed in other situations (e.g. someone smiling at them) take on a greater significance as their sensitivity is much greater. In addition, many feel that they are not qualified to make judgements about the medical care they receive. Hence, people feel vulnerable and how they are treated by members of staff – i.e. the way staff speak to them, pay attention to their individual circumstances and needs, the way staff make eye contact and smile etc. – all take on an added significance. It is important to ensure that these „softer‟ skills are adequately covered in staff training.

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4.4 Improving the ability of the Trust to obtain honest feedback from patients, visitors and staff and for people to feel that such feedback is being acted upon. Currently some patients do not feel empowered to give honest feedback about their care and do not feel confident that their comments will be acted upon. The results demonstrate that over a third of respondents would not tell staff if they had concerns about the quality of care in a hospital because they would be afraid that this would affect how they were treated on their next visit. A higher proportion of those who had been inpatients strongly agree with this statement (20% as compared with 17%). A third of staff say that there is scope to improve the way that feedback is collected from patients and acted upon. The vast majority of staff also say that improving the way that feedback is collected from staff and acted upon would help to show that their Trust puts quality of care as its top priority (80%).

4.5 Improving the information available to patients, the public and staff The results show that all groups do not feel that they have adequate access to information which would help them to make judgements about the quality of services. Only a small group of staff currently have access to information which would allow them to compare the quality of care provided by their ward or team with others either in the hospital or outside the hospital. Less than 15% of all staff who took part in the survey had seen information which would compare their performance with other wards or teams within the hospital and less than 10% of staff had seen information which would compare their performance with others outside the hospital.

4.6 Thinking about the ‘whole hospital experience’ for patients and visitors The findings demonstrate that patients and visitors make judgements about the quality of care being provided based on the whole experience of being in a hospital environment. Their judgements are holistic and not just about the medical care that an individual patient receives – indeed a good clinical outcome is usually taken for granted. For example, the research demonstrates that most patients take into account how they feel other patients are being treated when making judgements about quality (66%), and visitors make judgements based on how they see and hear other patients being cared for at the time of their visit, not just the patient they are there to see.

2

The Productive Ward aims to improve ward processes and environments to enable NHS staff to spend more time on patient care (www.institute.nhs.uk/quality_and_value/productivity_series/productive_ward).

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Hence, quality needs to be viewed holistically to encompass the whole hospital experience for patients and visitors. Trusts need to consider how patients can be better supported to understand how their care is being provided and how the wider ward is organised. Hospitals also need to consider what the experience of being in hospital is like for a visitor, how they are greeted by staff and supported in gaining an appropriate understanding how care is being provided for their relative / friend and other patients.

4.7 Improving the visibility of leadership at the ward level The visibility of leadership at the ward level is also central to how quality of care is perceived by patients and visitors. The focus groups reveal that there is very little awareness of how wards are currently managed, and this leads to a feeling that there is no-one to take responsibility for issues arising on a ward. When patients and members of the public were asked in the survey about practical steps that a hospital might take to improve the quality of patients care, they ranked „having a clearly identified leaderâ€&#x; on each ward or department as the most important measure, giving it a mean score of 8.81 out of 10. Although these individuals already exist, their profile needs to be raised amongst patients.

4.8 Improving patients’ perceptions of feeling involved and in control of their care The findings of the research demonstrate that while patients are very positive about the outcomes they receive from their care, a significant group of patients are dissatisfied with the amount of involvement patients have in decisions about their care (16%) and over a third disagree that patients feel in control of their care (34%). Around a quarter of staff feel that the amount of involvement (23%) and control that patients have over their care could be improved (27%). In other research, patients have been interested in more information on their condition and treatment, who is involved in their treatment, their likely length of stay, where to go for help and advice and how to complain. It is worth noting that not all patients want to be in control or involved in decisions about their care - preferring to defer to medical professionals - but as can be seen from these research findings, there is room for improvement for around a quarter of patients.

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1. Introduction

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1. Introduction 1.1 Background and objectives Providing excellent care is at the heart of the work of the NHS. Lord Darzi‟s review of the NHS, High Quality Care for All renewed the emphasis on quality, particularly emphasising the role of clinical staff within this agenda3. In order to ensure that work around quality is effective, there is a need to understand what the public, patients and staff think about the quality of local NHS secondary services, how they expect excellent care to be delivered, and to look at what information on quality people use and need. In line with these, a number of questions guided the research: 

How do patients, the public and staff in the West Midlands define excellent quality?

Do they think the local NHS hospitals currently meet these standards and why?

What do patients, the public and staff expect to see to judge if the NHS is meeting these standards? What does a hospital providing excellent care „look‟ like?

What are the perceived barriers to providing high quality of care?

What information do patients, the public and staff access, and what information would they like to be able to access about quality?

3

Department of Health (2008), High Quality Care for All

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1.2 Methodology The research has involved three phases – a literature review, a qualitative phase, and a quantitative phase.

Research design Key questions for patients, the public and staff = how do they define excellent quality care? Do they think the NHS meets these standards and why? What are the perceived barriers to providing high quality care? What do they expect to see to judge if the NHS is meeting these standards, and what does a hospital providing excellent care „look‟ like? What information have they accessed about quality and what would they like to be able to access?

Literature review on concept of quality

Informed discussion guides

Qualitative research to define quality and explore what would reassure people it was a top priority in the NHS

Patients – reconvened groups

General public – groups

Informed questionnaire design

Staff – reconvened groups, telephone depth interviews

Quantitative research on overall perceptions of quality of care and to assess performance on key elements of quality defined by qualitative research Patients and public – telephone survey

Staff – postal survey

1.2.1 Literature review The literature review looked at work already carried out on the concept of quality, and how that applies to patients, the public and staff in healthcare. It fed into the design of the materials for the qualitative and quantitative phases of the research, ensuring that this project built on the findings of previous studies. The findings from the literature review formed some of the prompts and questions in the discussion guide for the qualitative research.

1.2.2 Qualitative research The qualitative research comprised main three strands: 1. Patients – six discussion groups with West Midlands residents who had been to hospital as an inpatient or an outpatient in the last year, which were reconvened with the same participants around two weeks after the initial group; 2. General public – six discussion groups with West Midlands residents who had not been to hospital as an inpatient or an outpatient in the last year. Three were

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conducted with participants who had visited someone in hospital in the previous year, and three with participants who not had any interaction with a hospital environment; 3. Staff – five discussion groups, each with a particular group of staff (senior nurses, junior nurses, ancillary staff, scientists & technicians, and allied health professionals). The groups with senior nurses, ancillary staff, and scientists & technicians were reconvened with the same participants one or two weeks after the initial group. The initial groups with junior nurses and allied health professionals were followed up later with telephone interviews. In addition, four depth interviews (one-to-one interviews) were conducted by telephone with consultants. 4. Related streams of work were conducted around perceptions of cleanliness in hospitals and experiences of planned care. These pieces of work contained key elements of focus around quality which will be discussed within this report. They included a particular focus on people who did not have English as a first language and those with long term conditions. Full details of these groups are given in the appendices. Each discussion group lasted roughly 90 minutes, with the telephone depth interviews taking around 30 minutes. The qualitative stage took place between 19 January and 20 February 2009. A discussion guide was used to direct the discussions for each of the three audiences. A second guide was developed for the reconvened discussion guides with patients and staff. All guides were produced in consultation with the NHS West Midlands team. The discussions in the groups were moderated by an Ipsos MORI executive, who probed to ensure that all the objectives were covered, to explore what participants were saying and to cover all participantsâ€&#x; views. However, the aim of the group was for the participants to talk and react to each other, with the moderator moving the discussion along to ensure all areas were covered. Participants for the discussion groups with patients and the public were recruited face-to-face by Ipsos MORI recruiters, each group comprising around 10 people. Quotas were set on gender, age, social grade and ethnicity, to ensure a cross-section of residents were included. For the general public groups, quotas were also set on whether the participant had visited someone in hospital in the last year. Discussion groups with people who did not have English as a first language were included within the strands on cleanliness and planned care.

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Participants for the staff discussion groups were recruited through hospital Trusts4, each group comprising around five people. The hospitals recruited staff in the specified staff groups to take part in the research. These hospitals volunteered to help with the research as part of their work around quality. In order to build up a picture around each locality, the patient and public groups were also conducted in the same areas. The matrices below outline the specific composition of each discussion group:

Grp

Patient/ general public/ staff

Gender

Age

Social 5 grade

Ethnicity

Visited someone in hospital in the last year

Personally been in hospital in the last year

Number of people in group

1.

General public

Mixed

35-54

ABC1

White

No

No

9

2.

General public General public

Mixed

55+

C2DE

White

No

No

9

Mixed

55+

ABC1

White

Yes

No

8

General public General public

Mixed

35-54

C2DE

White

Yes

No

6

Mixed

35-54

Any

Asian

No

No

12

General public Patient (reconvened) Patient (reconvened)

Mixed

18-34

C2DE

Mixed

Yes

No

12

Mixed

18-34

ABC1

White

n/a

Yes

6/8

Mixed

55+

C2DE

White

n/a

Yes

6/6

9.

Patient (reconvened)

Mixed

35-54

C2DE

White

n/a

Yes

10 / 5

10.

Patient (reconvened)

Mixed

55+

ABC1

White

n/a

Yes

7/9

11

Patient (reconvened)

Mixed

35-54

ABC1

Mixed

n/a

Yes

9/9

12.

Patient (reconvened)

Mixed

55+

C2DE

Mixed

n/a

Yes

9/8

3. 4. 5. 6. 7. 8.

4

Hospital Trusts, or Acute Trusts, are organisations that provide secondary health services. A Hospital Trust may include one or more hospitals. Please refer to the glossary for more definitions. 5 Please refer to the glossary for an explanation of social grades

19


Grp

Patient / general public / staff

Staff group

Number of staff in group

13.

Staff – followed up with telephone interviews

Junior nurses, bands 2-5

4/2

14.

Staff – followed up with telephone interviews

AHPs

2/1

15.

Staff – reconvened

Senior nurses, bands 6-8

4/4

16.

Staff – reconvened

Technicians

3/3

17.

Staff – telephone interviews

Consultants

4

18.

Staff – reconvened

Ancillary staff

6/5

The discussion groups with patients and staff were reconvened – i.e. we spoke to these participants twice, with a gap between the two discussions. The aim was to get participants thinking more about quality in order to add another layer of thought for the second discussion. Following the first discussion, participants were given diaries to complete in the intervening period. Patients were asked to think about quality while they visited a couple of places they would normally visit in everyday life, such as a supermarket or library. They were asked to think about the quality of service they received on those visits. Ideally, a visit to hospital would allow them to think about quality while actually moving through the healthcare system. Staff were asked to think about quality in their day-to-day jobs, noting an occasion where they and the hospital were able to provide excellent quality of care to a patient and one where the quality could have been improved. Again, the aim was to provoke more thought on the topic. These diaries were then discussed and collected at the reconvened group. This qualitative research was used to inform the questionnaire design for quantitative surveys with patients, the public and staff. These surveys aimed to explore perceptions of quality among a wider audience and are used in conjunction with the qualitative research and literature review to present a rounded picture of quality in secondary care. The qualitative research focused the findings from the literature review, and pointed to areas that seem to be important and that therefore warrant further exploration with more people. A quantitative survey must by nature be more closed than qualitative research – and the qualitative research has helped to identify specific topic areas for the survey, as well as providing more depth to the survey findings.

20


1.2.3 Quantitative research Two pieces of quantitative research were conducted – one with patients and the public and one with staff. 1.2.3.1 The survey of patients and the public The survey of patients and the public consisted of 3,515 telephone interviews with West Midlands residents, each lasting for around 24 minutes. This included 1,857 residents who had been inpatients or outpatients in the last year, and 1,658 who had not. All interviews were conducted between 10 March and 14 April 2009. Quotas were set by PCT to ensure that the number of interviews gained in each PCT is proportional to the size of that PCT in relation to others in the West Midlands. Further quotas were set on gender, age, working status and ethnicity within each PCT to ensure that the profile of those interviewed matches the profile of each PCTâ€&#x;s population as closely as possible, according to the 2001 census, updated with reference to the latest ONS mid-year population estimates. Data were also weighted by the size of each PCT and then the gender, age, working status, ethnicity and social class profile within each PCT according to the 2001 census updated with mid-year estimates. 1.2.3.2 The staff survey Seven Trusts in the West Midlands volunteered to take part in this research. Self-completion questionnaires were sent to 4,200 staff working in these Trusts. Staff were randomly selected to take part in the survey, the sample was drawn from the full staff lists of the Trusts. Fieldwork was conducted between 24 April and 8 June 2009. The total number of questionnaires returned by post was 1,030, giving an unadjusted response rate of 25%. Data are not weighted. Please note that where reference is made to the West Midlands average for staff, this refers to the average across all the staff who took part in the research, across the seven Trusts. The volume of responses and the systematic sampling approach adopted, should give a good insight as to the views of staff in the West Midlands, however, the results are not wholly representative of all staff in the West Midlands.

21


1.3 Presentation and interpretation of the qualitative data It is important to note that qualitative research is designed to be illustrative rather than statistically representative and therefore provides insight into why people hold views, rather than conclusions from a robust, statistically valid sample. In addition, it is important to bear in mind that we are dealing with people‟s perceptions, rather than facts. Throughout the report, use is made of verbatim comments from participants. Where this is the case, it is important to remember that the views expressed do not always represent the views of the group as a whole, although in each case the verbatim is representative of, at least, a small number of participants.

1.4 Presentation and Interpretation of the survey data It should be noted that a sample, and not the entire population, has taken part in the survey. Therefore, all results are subject to sampling tolerances, which means that not all differences are significant. A guide to statistical reliability is appended, but as a rule of thumb results based on the full patient and public sample are reliable to +2 percentage points, while results based on the full staff survey sample are reliable to +3.1 percentage points6. For both surveys sub-groups will have a wider margin of error. Any results based on samples of 100 or below have a margin of error of at least +10 percentage points, and should be treated as indicative only. It should be borne in mind that demographic sub-groups overlap, and that viewing them in isolation can be artificial. For example, ethnic minority communities often have a younger age profile; differences in their views may be just as much to do with age as they are to do with ethnicity. Where percentages do not sum to 100, this may be due to computer rounding, the exclusion of “don‟t know” categories, or multiple answers. Throughout the report an asterisk (*) denotes any value of less than half of one per cent, but greater than zero. Where reference is made to “net” figures, this represents the balance of opinion on attitudinal questions, and provides a particularly useful means of comparing the results for a number of variables. In the case of a “net satisfaction” figure, this represents the percentage satisfied on a particular issue, less the percentage dissatisfied. For example, if 40% who answer are satisfied and 25% dissatisfied, the “net satisfaction” figure is +15 points.

6

All figures are based on the 95% confidence interval.

22


1.5 Report Layout This report has the following structure: 1. Defining excellent care – exploring how patients, public and staff think about quality in relation to secondary care. 2. Views on the dimensions of quality in local secondary care services – looking at what patients, public and staff think about the quality of hospital services in the West Midlands. 3. Perceived barriers to providing excellent quality of care – uncovering what patients and the public think makes it difficult for hospitals to provide excellent quality of care, along with what staff feel would make it easier for them to deliver this excellent quality. 4. Quality at the heart of the NHS – exploring what priorities patients, the public and staff think their NHS hospital has, along with what would reassure them that quality is a top priority and the practical measures a hospital could take to demonstrate this. 5. Accountability – looking at the importance of accountability to patients, the public and staff, and understanding how they want to hold hospitals to account. 6. Information provision – looking at whether patients, the public and staff have accessed any information about quality, and what they would like to be able to access.

1.6 Publication of data Our standard Terms and Conditions apply to this, as to all studies we carry out. Compliance with the MRS Code of Conduct and our clearing is necessary of any copy or data for publication, web-siting or press releases which contain any data derived from Ipsos MORI research. This is to protect your reputation and integrity as much as our own. We recognise that it is in no-one‟s best interests to have findings published which could be misinterpreted, or could appear to be inaccurately, or misleadingly, presented.

23


1.7 Acknowledgements Ipsos MORI would like to thank Louise Jackson, Peter Spilsbury, Steven Wyatt, Kiran Patel, Maggie Bayley, Fay Baillie, Viv Tsesmelis and Peter Blythin for their help and assistance in the development of the project, along with contacts at the Trusts who organised the staff research. We would also like to thank all the members of the public and staff who attended the groups and depth interviews and completed interviews and questionnaires, without whose input the research would not have been possible.

ŠIpsos MORI/J35243 David Jeans Jayesh Shah Leila Tavakoli Wendy Floyd Kate Duxbury Caroline Booth

24


2. Defining excellent care

25


2. Defining excellent care This chapter explores what excellent care means to patients, the public and staff, looking at what is important to them when thinking about quality in secondary care. The literature review uncovered many different definitions or dimensions of quality. Both as a concept and as a practical and measurable goal, it has proved difficult to define in healthcare. However, consensus at the national and international level is emerging that in order to improve and monitor performance the following dimensions of quality need to be recognised: 

safety;

effectiveness;

appropriateness;

responsiveness (patient-centred care);

equity;

efficiency;

outcomes of care;

timely access;

value for money;

capacity;

healthy, independent living; and

health improvement7.

This research aimed to build on previous studies by examining people‟s experiences and expectations around quality in the local context. Much of this work was qualitative, as it is better suited to this form of exploration. We spent a considerable amount of time talking with patients, members of the public and staff about how they defined high quality care. The intention was to feed these findings into the quantitative surveys so we could also measure perceptions of those aspects considered key to quality, which is analysed in the next chapter.

7

McLoughlin, V and Leatherman, S (2003) Quality or Financing: what drives design of the health care system? In Qual. Safe. Health Care & Raleigh, V and Foot, C (2010) Getting the Measure of Quality, The King‟s Fund

26


Summary Patients and the public stressed that they thought about quality differently in relation to NHS services in comparison with other services. The participants in the groups felt that the emotional impact of going to hospital and being vulnerable made it a somewhat different interaction. Numerous factors fed into the definitions of quality provided by members of the public, patients and staff, although each group placed varying levels of importance on each factor. Nevertheless, treating patients as individuals was a strong theme that ran throughout all of the groups, for patients, the public and staff, and this was often thought to compensate where other aspects, such as waiting times and facilities, fell short. This patient focus underpins all of the areas that participants defined as contributing to excellent quality. It involved staff having the time to talk to patients about their treatment and explain it to them, and involve them in decisions. It included the way that staff interact with patients, with particular mention of them needing to be warm, friendly and approachable. Participants also mentioned that the ways in which other patients were treated would have an impact on their views, particularly the perceived treatment of patients they felt to be vulnerable. Despite the overriding public view that the NHS is there to “make people better�, patients and the general public tended to put less emphasis on the quality of the actual clinical treatment than staff did. This is partly because they would find it difficult to judge how good or poor their treatment was, but there was also a feeling that a healthy outcome was simply expected. Clinical staff in particular talked about good medical outcomes as central to quality.

27


2.1 Making judgements about quality in secondary care One of the aims of the research was to explore how people think about quality in relation to secondary care. The discussion groups were reconvened to allow people to reflect on their thoughts and experiences, and to consider the judgements they make about quality in their everyday lives. The participants in the focus groups did feel that there were some important differences in how they thought about quality in relation to NHS hospitals, compared with other places that were important to them. They stressed that their state of mind while at hospital was much different to their state of mind when shopping in their local supermarket or socialising with friends. The emotional impact of visiting a hospital often meant that they had very high expectations of the care they should receive and things that would normally go unnoticed in other situations (such as whether or not a shop assistant smiled at them) were of greater significance in hospital, when their sensitivity to these things was much greater. In particular, participants stressed their feelings of vulnerability when they or their relatives were going in to hospital. It’s your organs, it’s your blood, your body, and you’re putting that into somebody else’s hands. Male, 18-34, Patient This feeling that there are differences in the ways people think about quality in the hospital environment is significant in setting the context for discussions around the factors which people identify as important in defining excellent care.

2.2 Patient focus: empathy, respect and communication For patients and public, individual treatment meant having a consultant or doctor taking the time to read their notes, talking them through and involving them in their treatment and making sure they knew exactly what was going to happen to them while they were in hospital. It was also about nurses having the time to talk them through anything they did not understand, as well as occasionally stopping to say hello on the ward. When you walk into a hospital, you want to be greeted by somebody who is going to listen to what, why you’re there, and then tell you to go to the appropriate place to get the treatment that you need for the reason that you’re there. And then when

28


you’re directed to where you should be, again, you want to be greeted and treated. Female, Under 35, General Public

Just listening to the patient, the person and taking what they know about their own body. Female, 35-54, Patient

The way in which this information was relayed was also a key consideration, with many participants describing small things, like eye contact and a smile, as making a big difference to their overall experience. Patients described feeling anxious and vulnerable during their visit and felt that good quality care would involve staff taking this into account when they communicated with them. They felt that nurses had an important role to play in this regard, particularly as they tended to have the most frequent contact with patients and were often the only visible staff on the wards. Empathy is what is needed for the medical staff to try to understand what you might be experiencing. That seems to be lacking now when it was not lacking 30 years ago. Female, 35-54, Patient

In addition to how staff communicated with them personally, participants in the patient groups noted that the welfare of other patients they saw while at hospital would also affect their opinion of the quality of care. For example, seeing other people on trolleys left unattended in the hospital corridor created the impression that patients were not being looked after. This often affected their view of the hospital, even if their own care was of high quality. You can have the best care in the world, but it still rubs off to see these other people who are by the side of you that have been waiting half an hour before you get there, they’re still there when you’re gone. Male, 55+, Patient

Feedback from some patients from ethnic minority groups highlighted the importance of staff being sensitive to an individual‟s cultural and religious background. While participants in

29


these groups were generally positive about the care they had received, some did highlight cases where staff had demonstrated a lack of understanding and respect. There seems to be this assumption that if you’ve got brown skin you’re all the same… I’m not a Muslim. And I don’t expect the nurse or the doctor … anyone there to write down Muslim and for me to correct them... As Sheikhs, we do not eat Halal food. And we were handed the Halal menu. Male, 35-54, South Asian patient

The importance of caring for the individual was also discussed in the staff groups, particularly among front line staff, who believed that having a certain level of emotional intelligence helped them to provide the care that patients needed. They recognised the importance of involving patients in their treatment and also felt they had a key role to play in ensuring patients felt confident about the care and treatment they were receiving. In addition to this, ensuring that patients were comfortable and their needs were being met was a central priority. Make them feel part of the decisions that are made, that you’re not making decisions over them, you’re empowering your patient, really, to make their own decisions. Staff member

To me, quality means looking at your patients, are they comfortable? Are they pain free? Do they look like they’re cared for? Are they, have they had their dressings done? All the things that are important to a patient. Have they been fed? Can they get to their drink? Have they got fresh water? That’s quality to me, looking after your patient, making sure they’re comfortable, they are happy in their environment. Staff member

Just make sure the patient’s comfortable and make sure that they’ve got all, everything they need and that’s that. Staff member

30


The staff groups also felt that good internal communication contributed to the provision of excellent quality of care. Examples such as ensuring a patient‟s file was in the right place at the right time, briefing colleagues at the end of each shift and having appropriate processes in place to record and deal with errors were all discussed as important aspects of care provision. Non-clinical staff felt there should be more communication between them and clinical staff to avoid conflicting priorities, such as patients having physiotherapist visits while ward service officers are trying to serve lunch. The Protected Mealtimes Initiative was introduced in 2004, aiming to allow patients to eat their meals without unnecessary interruptions and to give time for staff to help those requiring assistance with eating. The comments made by staff might indicate a lack of consistency in terms of awareness of this initiative or a lack of ability to adhere to it in practice. Within the discussion groups staff were not asked about the initiative specifically, so further analysis around this issue might be helpful. Yeah, I don’t think the wards communicate with each other, the individual staff, and as I say the departments don’t… fill each other in properly on what’s going on. Staff member

Or the doctor will turn up for the visits when they’re having the lunch, … I said to them once, can’t they do it at a different time, not when they.., because one time the meal was cold, they come back, either [its] cleared away so they can’t eat their meal or there’s nothing for them to eat. Staff member

2.3 Waiting times Waiting times when actually at the hospital were a common topic of discussion in the patient groups. Some thought that reducing waiting times would feed into what they defined as excellent quality of care. However, others felt that long waiting times were sometimes inevitable and that this was acceptable, provided they were in a dedicated waiting area and staff kept them informed about why they were waiting and when they should expect to be seen. Moreover, the requirement for shorter waiting times was often seen as counterintuitive to the provision of individual care, which was seen as more important.

31


They’re telling you if you’re going to have to wait or anything, you do have to wait sometimes and, for certain things, but they always let you know what was going on. Male, 35-54, Patient

It’s very important that you’re being seen when you arrive but when you get quality of care, you forget about the time you’ve waited for. Male, 55+, Patient

I know if I’ve got… 15 minutes… I can go back outside at least and have a cup of coffee or something. At least you know where you stand. Male 55+, Patient

Waiting for an appointment in the first place was also a source of frustration for some patients, particularly those whose condition was causing them pain. It was generally appreciated that more serious cases (e.g. people with life-threatening illnesses) should take priority in the appointment booking system but the fact that some patients had waited for months to receive treatment inevitably had an impact on their perceptions of the quality of care. However, in line with discussions about waiting times in hospital, patients agreed that the time they had waited for an appointment was less of an issue, if the care they received in hospital was good (provided their condition was not life threatening). The comments made about waiting times and living with pain, seem to suggest that more can be done to improve the experience of integrated care – with primary and secondary care providers working together more effectively to manage the patient‟s condition. In addition, improved patient awareness of integrated care pathways might help to improve perceptions and experiences around waiting times. Patients having a timely discharge also factored in the definition of excellent quality of care for some (good link up with social care and not having to wait for medication, for example), although this was less widely discussed.

32


2.4 Hospital environment and facilities Despite the emphasis on communication and individualised care, environmental factors were also a major consideration in all groups. Excellent care had to be provided in a “pleasant” environment that was fit for purpose, appeared clean and odour-free, and this was an underlying requirement of all patients. Cleanliness was of paramount importance but in relation to quality, it was often linked to other factors, such as communication and leadership. You want cleanliness in there when you go in. You want to see a nice, shiny floor, you don’t want to see tea spots everywhere. You want somebody there picking up if anybody is making a mess and say two security people or something thinking, welcoming people on the reception or something. Female, 18-34, Asian, Patient

One of the key findings of the research around cleanliness was that people wanted to feel reassured about responsibility and accountability. They wanted to know who was responsible for keeping a particular area clean, and that an easily identifiable individual would be accountable for making sure that high standards were maintained. If you don’t have someone responsible for cleanliness in each ward individually who report back to a head person, then nothing will get done. One person cannot watch over staff throughout the entire hospital...and if this person is there now, then they are not making themselves identifiable. Male, 35-54, Mixed Ethnicity Group Staff participants agreed that people valued staff visibly making an effort to improve cleanliness, even in terms of their dress and appearance. Patients… want to look at somebody who they perceive is clean and tidy, and will look after them in that manner, wash their hands correctly. And part of that is having your hair tied back, and looking like a nurse. Staff member

33


Something that was rarely mentioned in the patient and public groups was the quality of the equipment available. However, this was a topic that came up in some of the staff groups– particularly in relation to being consulted on changes to equipment provision. And those new trolleys you can’t even turn them round a corner, you have to drag it around there… they should ask the people that are doing, using the thing, equipment day by day. Staff member In addition, ensuring that patients had good quality food provided at regular intervals was an important consideration among all participants in relation to high quality care. Staff in particular stressed how important this was for a patient‟s recovery and some felt that it was as important as individual treatment, communication, cleanliness and leadership. And making sure people have something to eat and drink that’s worth eating and drinking.

And these things make a big

difference, there’s a lot of scientific evidence that nutrition is really important in recovery from illness. Staff member

Also mentioned in conjunction with excellent quality of care were: well managed visiting hours; affordable and appropriate parking; having a dedicated smoking area (away from the hospital entrance); and making all wards single sex – though, again, these issues were less widely discussed.

34


2.5 Clinical treatment and standards It is interesting to note that the quality of clinical treatment was rarely considered in the patient and public groups. This is partly because they assumed that their treatment would be successful, but they also felt unable to judge the quality of this because they did not have sufficient knowledge and understanding of the clinical side of their treatment. I think if you see a consultant, you take it for granted that they’re at the top of their game. Female, 18-34, Patient

The exception was a group of general public participants from a South Asian ethnic background. These participants talked about the importance of a correct and timely diagnosis. They felt this had not happened with their friends and family, and as a result of these experiences, said it was the most important part of providing good quality care. They cannot diagnose what illnesses you’ve got. Even if you talk to the doctor and you say this is what’s wrong with me, but what is causing the problem, it’s very, very, difficult for them to identify so when you end up in the hospital they start from scratch and take so long, and sometimes the patient dies before they find out what’s wrong with them. Male, 35-54, General Public, South Asian While staff did recognise the importance of medical treatment in the qualitative research, they also felt that communication and leadership were extremely important in providing excellent care. Clinical staff did place greater emphasis on the quality of treatment than nonclinical staff. I think first of all the people looking after the sick person must know what they’re doing and must know what they’re looking for and know how to deal with whatever situation confronts itself. Staff member

35


I think care also works on a much more basic level as well in terms of the day to day needs that people have, that’s being clean, warm, dry, well fed and just being treated like a human being. Staff member

I think most of the patients that I talk to are generally fairly happy with their care and talk highly of the treatment they’ve got but what are they comparing it with? Staff member

I think if you look at what clinicians think good quality of care is outcome data and it’s, by outcome I mean that the patient survives, the patient does well, everything was successful as far as clinical results are concerned and that the patient is happy with the interaction they’ve had with medical and paramedical staff. Staff member

Staff tended to recognise that their patients‟ definitions of quality could differ from their own. Some described occasions where they felt the care they provided was not high quality, but their patient was satisfied. If somebody gave that tablet and there’s another tablet that’s better, they [the patient] wouldn’t know. Staff member

Some staff also talked about the quality standards outlined by their Royal Colleges or other national organisations, often outcome measures, which also played an important role in defining quality. Our national body has issued quality standards that we have got to work towards.

So we are constantly auditing these

things, all hospitals are supposed to be looking at these things. Staff member

36


2.6 The importance of dimensions of quality for different groups The table below summarises the importance of different dimensions of quality for patients, public and staff, based on the findings of the qualitative research. Some differences are evident between groups; as we might expect, staff are more likely to highlight factors such as internal communication and the quality of equipment.

Dimensions of quality identified in the qualitative research

Importance for patients and public

Waiting times when at the hospital

Treating patients as individuals

Affordable and appropriate parking

Spending time with patients

Dedicated smoking area away from the hospital entrance

Explaining treatment to patients Involving patients in decisions

Reducing anxiety Cleanliness Good quality food Well-managed visiting hours

Timely discharge Single-sex ward Internal communication Quality of equipment Quality of clinical treatment (taken as a given for public & patients)

Importance for staff

The next chapter discusses what patients, the public and staff say about the quality of secondary care services in the West Midlands.

37


38


3. Views on the quality of local secondary care services

39


3. Views on dimensions of quality in local secondary care services The previous chapter discussed what excellent care means to patients, the public and staff. This chapter analyses perceptions around the different dimensions of quality identified in the previous chapter.

Summary Patients, the general public and staff are generally positive about most aspects of care provided by their Trusts. Satisfaction with clinical treatment, the outcome of care and the way and manner in which staff deal with patients – such as being friendly, polite and professional – are all fairly high, with positive perceptions among the majority of all three groups. That said, there are aspects which were highlighted as areas for improvement: perhaps the most important of these aspects, given its prime role in influencing perceptions of excellent quality of care, is increasing the amount of time staff have to spend with patients; patients, public and staff also all raise aspects of communication and coordination, both within the hospital and between the hospital and the GP, as areas where they are relatively less satisfied; patients, public and staff are also less satisfied with waiting times between first referral and hospital appointment and waiting times while in hospital; patients and the public are considerably less satisfied with the facilities patients can access, such as television, telephones and parking; levels of satisfaction among patients and the public around levels of infection are also fairly low, however staff are more positive about improvements in hospital infection rates; patients the public and staff are all less satisfied with the quality of hospital food; and staff in particular feel that collecting and acting on feedback from patients could be improved.

40


It is worth noting that, despite generally good findings around outcomes, clinical staff are more polarised than other staff around providing safe care – significant proportions of nurses and midwives , and doctors and consultants (around one in four) feel at least a fair amount of improvement is needed in providing safe care. This may simply be a due to clinical staff being more directly involved and aware of potential safety issues than staff more generally.

3.1 Patient focus 3.1.1 Public and patient views on patient-focussed care As mentioned previously, patient focus underpins all of the aspects of quality that patients, the public and staff considered important. The majority of residents are satisfied with the outcome of care for the patient. Four in five think they personally, or other patients, received a good outcome from their care (80%), and two in five are very satisfied with this (41%). Residents are generally satisfied with the fact that patients are treated equally (71%), the privacy given to patients (69%) and the flexibility of visiting hours (67%). However, there are areas where less satisfaction is evident, as explained further below.

Patient focus: patient and public perceptions Q

And from what you know or have heard, how satisfied or dissatisfied are you with each of the following aspects of your local NHS hospital? % Fairly satisfied % Very dissatisfied

% Very satisfied % Fairly dissatisfied You/patients received a good outcome from your/their care

41

All patients are treated equally, with the same quality of care

% Neither/nor % Donâ€&#x;t know

39

34

Net satisfied

4 5 4 7

37

5 6 6

The privacy given to patients

29

The flexibility of visiting hours

28

39

6

Aftercare patients receive once they have finished their treatment

27

38

5 8 5

The amount of involvement patients have in decisions about their care Patients getting peace and quiet while in the hospital

40

21 18

7

41 36

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

41

9 9

16

11 10

6

+71

12

+59

7 6

+51

11

+50

14

+51

10 5

13

+47

8

12

+30


Just over 60% of respondents are satisfied with the amount of involvement patients have in decisions about their own care, which leaves a third who are not satisfied or who do not know. The graph overleaf demonstrates that an even lower proportion are satisfied that patients feel in control of their care. Just 42% agree that patients feel in control, and 34% disagree.

Patients feeling in control: patient and public perceptions Q

From what you know or have heard, to what extent do you agree or disagree with the following statement? Patients feel in control of their own care. No opinion

Strongly agree

13%

14% 42% Agree

Strongly disagree 13% 34% Disagree

to 28% Tend agree Tend to disagree

21% 11%

Neither agree nor disagree

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Net agree: +8

This highlights the fact that while a majority of respondents are satisfied with the involvement patients have in their care, less than half are satisfied with the control they have. Some insight as to the difficulties in feeling „in control‟ is evident from the qualitative work where people described their feelings of vulnerability when going into hospital. In addition, some of the research suggests that a lack of understanding as to what is happening can help to reduce the control people feel. Those who felt that their care and treatment were fully explained tended to be more positive about their experiences. They talk to each other about what’s wrong with you… they use the doctors’ terms, which, like, you don’t really understands half the time… they don’t even tell you straight to the point what’s wrong with you Male, age 16-34, Planned care group

42


I was told from the minute I got there ‘till when I came out exactly what was going on, and they even gave me a pamphlet when I left explaining everything to me Female, age 35-54, Planned care group

Those who have recent experience as a patient at their local hospital tend to be more favourable across all the aspects of quality that focus on the patient, including involvement and control. For example, 71% of inpatients are satisfied with the involvement patients have in deciding their care, compared to a 62% average of the general public. Those who have been an inpatient are also more positive about patients feeling in control of their care (48% agree, compared to a 42% average). However, the fact that this is only half of the group is clearly a cause for further investigation. 8 Those who have visited someone at an NHS hospital in the past year are often more negative about various aspects of quality that relate directly to the patient. For example, they are more likely to feel that patients are not in control (40%, compared with 34%). Similarly, they are more dissatisfied about the flexibility of visiting hours (20% dissatisfied, compared to a 16% average). The research suggests that more could be done to make the patient focus more visible to visitors. Although satisfaction with patients getting peace and quiet in the hospital is relatively low – just over half are satisfied (54%) and almost one in four are dissatisfied (24%) – participants in the discussion groups acknowledged that such concerns often tended to be in relation to other patients being disruptive or overly demanding, possibly leaving them outside of the hospital‟s control. This was commonly mentioned as having a negative impact on the quality of care delivered as nurses inevitably had to divert attention away from others to deal with these “difficult customers”. Some participants – patients, public and staff alike – recognised that patients and visitors had their own responsibilities.

8

Younger people are particularly likely to say patients feel in control (53% of 16-24 year olds and 47%

of 25-34 year olds). Probably linked, as they tend to be younger, Asian residents are more likely to agree that patients feel in control (52%, compared to 42% overall). Disagreement is higher than average among those aged 45-54 (41%, compared to 34% on average) as well as among those with caring responsibilities (39%).

43


You can’t really say because there are some patients that are always crying out for something so obviously the nurses are aware that they don’t need to attend to that patient so. Staff member

There was a family in the next bed that literally ran riot... my daughter was trying to sleep, I was getting really riled because these kids were throwing things at us, and the parents sat there and laughed as well, and I thought, it’s not just the care of the nurses. Female, 18-34, General public

3.1.1 Staff views on patient-focussed care Perceptions of patient-focused care among staff are generally positive and appear to be fairly consistent with the views expressed by the general public. That said, staff clearly highlight the end of the care pathway as the weakest link in the chain, with 26% stating that the aftercare patients receive once they have finished their treatment is in need of a „fair amount‟ or „a lot‟ of improvement.

Patient focus: staff perceptions Q

Thinking about quality of care in your trust, please indicate whether each of the following areas is in need of no improvement, in need of a little improvement, in need of a fair amount of improvement or in need of a lot of improvement. Net % Don't know % A fair amount % A lot improvement % A little % No need for improvement % Not stated needed

Collecting feedback from patients and acting on feedback Aftercare that patients receive once they have finished their treatment

13

21

33

9

17

The privacy given to patients

9

16

39

Patients feeling in control of their own care The systems and procedures in place to follow-up when things don‟t go as planned Involving patients in decisions about their care Patient views on whether the care they have received has improved their health Treating patients equally with the same quality of care

8

19

36

7

22

The procedure for patients to make complaints

6

37

13

38

11

36

2 10

Base: All staff members (1,030); fieldwork dates

39

17

6 5

32

24th

32 April -

8th

June 2009

44

4 +11 12 25 5 +18 22 10 4 +36 14 19 5 +22 10 17 4 +20 20 15 4 +33 11 29 4 +30 34 10 4 +54 36 17 3 +56 12

17


Turning to patient feedback, one in three staff members feel that collecting feedback from patients and acting on that feedback is in need of a lot or a fair amount of improvement (34%). Other aspects such as the systems and procedures in place to follow-up when things donâ€&#x;t go as planned (29%) and the level of aftercare that patients receive once they have finished their treatment (26%) are also seen as relative priorities for improvement. Staff were more positive about the fact that patients are treated equally, with the same quality of care, patient views on their health outcomes and involving patients in decisions about their care (16%, 19% and 23% respectively stated that these areas need a fair amount or a lot of improvement). Interestingly, staff make much less of a distinction than patients between the level of involvement patients have in decisions about their care and the level of control they feel they have over their care, rating both at a similar level. In contrast, patients are more satisfied with the involvement they have than with feeling in control of their own care. Further work to explore these differences would be needed to explain any potential variation in interpreting notions of involvement and control. Perhaps unsurprisingly, those staff members who have the most regular contact with patients and the general public are also the ones who are most likely to express an opinion either way about the vast majority of the patient focused aspects of care. Nurses and midwives are more likely than staff in general to feel that collecting feedback (42% compared to 34% on average) and the systems and procedures in place to follow-up when things donâ€&#x;t go as planned (35% compared to 29%) are in need of a lot or fair amount of improvement. Conversely, they are also more likely than staff in general to feel that patientsâ€&#x; perceived level of autonomy in their care, the aftercare they receive and the complaints procedures are all only in need of a little or no improvement. Length of service also appears to hold a certain level of influence over the views of staff. Those staff with less experience tend to be more likely than their longer serving counterparts to feel that patient focused aspects of care do not need improving. Staff who have worked for the NHS for less than ten years are more likely to feel that treating patients equally (40% compared to 30%), the privacy given to patients (27% compared to 18%), and patients feeling in control of their own care (17% compared to 11%) are not in need of improvement.9 A similar pattern is seen when looking at the age of staff, with younger staff less likely than their older colleagues to feel that patient focused aspects need improving. Some of the

9

Compared with those who have worked in the NHS for ten years or more.

45


reasons why older and more experienced staff are more negative about patient focus aspects of care will need to be examined by Trusts.

3.2 Interactions between patients and hospital staff 3.2.1 Public and patient views on interactions with staff The quantitative research suggests that, in the main, residents are satisfied with the way patients are treated by hospital staff, when they are able to talk to them. The vast majority believe staff are friendly (86%), polite (86%) and professional (84%). Four in five believe that staff treat patients with dignity and respect (80%) and the same proportion are satisfied with the level of expertise staff have. Inpatients and outpatients are considerably more likely to be very satisfied with all these aspects, and tend to be more satisfied overall.

Conduct of hospital staff: patient and public perceptions Q

And from what you know or have heard, how satisfied or dissatisfied are you with each of the following aspects of your local NHS hospital? % Very satisfied % Fairly dissatisfied

% Fairly satisfied % Very dissatisfied

% Neither/nor % Donâ€&#x;t know

Net satisfied

Friendliness of staff

49

38

6 3 23 +81

Politeness of staff

49

38

5 4 23 +80

Professionalism of staff

46

Staff treat patients with dignity and respect

42

Staff expertise The amount of time doctors and consultants spend with patients The amount of time nurses spend with patients

5 4 3 4 +78

39 38

39

41

24

40

21

39

7 8

5 6 4 5

+69

5 43 8

+73

7

8

+44

11

+38

14 13

8

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

However, when considering the amount of time patients actually spend with staff, the proportion of residents satisfied falls to 64% for doctors and consultants, and just 60% for nurses. One in five residents are dissatisfied with the amount of time doctors/consultants and nurses spend with patients (21% dissatisfied for each). Nevertheless, inpatients themselves are much more content with the time nurses spend with them (70% satisfied, compared to a 60% average). Satisfaction with the time doctors/consultants spend with

46


patients is also somewhat higher among inpatients and outpatients (69% each, compared to 64% overall). However, as patients are consistently more positive when asked about hospital care, the fact that they rate this aspect lower than others indicates more concern on this issue.

Conduct of hospital staff: patient vs. public perceptions Q

And from what you know or have heard, how satisfied or dissatisfied are you with each of the following aspects of your local NHS hospital? Patients

Public

% very satisfied

53%

Friendliness of staff

44% 53%

Politeness of staff

44% 49%

Professionalism of staff

41%

Staff treat patients with dignity and respect

47% 36% 43%

Staff expertise The amount of time doctors and consultants spend with patients The amount of time nurses spend with patients

35% 29% 18% 24% 17%

Base: All inpatients or outpatients (1,857) British adults, all public (1,658); fieldwork dates 10th March – 14th April 2009

In general, patients and the public in the qualitative groups also felt that although front-line staff were committed to providing high quality care, this was constrained by the actual time they spent with patients. While many patients had had very positive experiences (anecdotes, such as a nurse holding their hand when talking to them or addressing them by name, were common in the patient groups), most patients and public felt that nurses were often too busy to tend to the individual needs of patients – a perception that was often created by people‟s observations of staff presence on the wards. In fact, one participant in the general public groups recalled helping another patient eat his evening meal because he was not capable of feeding himself and there were no nurses around to attend to him at the time. Others described similar examples of patients requiring help but not being attended to by staff. This impression is also held by those who have visited others in hospital – they are more dissatisfied with the time nurses spend with patients than residents overall (27% dissatisfied, compared to 21% overall).

47


A few years ago when she [participant’s relative] was in hospital… there was a lady in the bed next to her who was blind… and they just put her dinner and her pudding on the tray and that was it. And they said, oh, your dinner’s here, and that was it, she moved on. Female, 55+, Patients

3.2.2 Staff views on interactions with patients The results from the quantitative staff survey mirror those expressed by patients and the general public. Issues with the amount of time that staff spend with patients is seen as the area most in need of improvement, signalling dissatisfaction from patients and staff alike. Around one in three staff cite spending time talking to patients more generally (34%) and spending time with patients discussing their condition and treatment (30%) as areas in need of a lot or a fair amount of improvement, while a similar proportion also mention the training and expertise of staff as a priority area (28%). In contrast, a far lower proportion of staff mention being friendly, professional and polite to patients (14%) and being kind to patients (15%) as areas in need of a lot or a fair amount of improvement.

Patient and staff interactions: staff perceptions Q

Thinking about quality of care in your trust, please indicate whether each of the following areas is in need of no improvement, in need of a little improvement, in need of a fair amount of improvement or in need of a lot of improvement. Net % Don't know % A fair amount % A lot improvement % A little % No need for improvement % Not stated needed Spending time talking to patients more generally

12

Spending time with patients discussing their condition and treatment

11

The training and expertise of staff

6

The quality of customer service provided by staff

5

Being friendly, professional and polite to patients

37

19

8

Treating patients with dignity and respect

Being kind to patients

22

14

38

21

15 52

11

39

17 39

3 10

48

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

48

+18

4

+23

53

+35

10 4

+53

8 4

+43

9 4

+58

52

+65

13 11

30 50

4 11

11 4

16 34 31


Nurses and midwives and those staff members who have worked in the NHS for ten years or more particularly tend to highlight the lack of time spent both talking to patients more generally (46% and 39% compared to 34% overall), and about their condition and treatment (43% and 35% compared to 30% overall respectively), as areas in need of a lot or a fair amount of improvement. Staff in the discussion groups tended to feel that their ever increasing workloads affected the amount of time they could spend with patients. They felt that this had a knock-on effect on their ability to provide individualised care and communicate well with each patient. The communication has got more difficult, because your time is much shorter. Whereas before, if somebody needed it, I could spend half an hour with them, talking to them, before, now I’m lucky if I see them for five minutes. This really has changed quite a lot. Staff member

Some staff also felt that the shorter lengths of time patients spent in hospital made it more difficult to build up a good relationship with them and provide excellent quality of care. They closed the, shorten the hospital stay, with a hip it’s, they’re now in two or three days, where it was a week, so you've got a short time to get everything done to get them out. Staff member However they also believed that, on the whole, they personally were providing a good standard of care and could think of numerous examples of this. I’ve had patients that have said in different wards that they’ve had good care, good service in this hospital. Staff member

That is why all of us are in existence in the NHS, to provide good, optimum quality of care, when the patient needs it, at the point that they access the service. Staff member

49


3. 3 Hospital communication and coordination 3.3.1 Public and patient views on communication and coordination In the qualitative groups many patients shared their positive experiences about hospital staff explaining their care and treatment to them and dealing with any queries. As we have seen, patients place high importance on staff being able to explain their treatment clearly to them. However, patients‟ experiences of communication with hospital staff seemed extremely varied. Many described having very little time to discuss their diagnosis and treatment with a doctor and therefore had to rely on nurses to provide the explanations and reassurances they were seeking. Moreover, while patients were confident that consultants and doctors were well trained and knowledgeable in their field, many felt that they lacked the necessary people skills required when dealing with potentially frightened and vulnerable individuals. This view was particularly prevalent among the C2DE participants (please see Appendix 2 for definitions of social grade), who were more likely to describe doctors and consultants as aloof. The doctor wouldn’t look at mum or anything; he was talking and discussing her situation as if she wasn’t there. Female, 35-54, Patient

People are not cases, they’re people… Feelings, fears, worries, and they need to be informed in a manner in which they can understand of what’s happening to them, what medications they’re given, what possible side effects they may. I mean how many people here have been given medication by a doctor and not told what the side effects may be? Female, 18-34, Patient

Talk to you as if you’ve got a modicum of intelligence, because I think sometimes they’re inclined to talk down to you. Female, 55+, Patient

She’d got no time for her this doctor, and she goes, oh I haven’t got time for you telling me about you, I’ve got other people to see, and she just walked off and left her. Female, 55+, General public

50


Looking at the quantitative research, residents‟ satisfaction with aspects of internal and external hospital communication and coordination varies.

Hospital communications and coordination: patient and public perceptions Q

And from what you know or have heard, how satisfied or dissatisfied are you with each of the following aspects of your local NHS hospital? % Fairly satisfied % Very dissatisfied

% Very satisfied % Fairly dissatisfied

Staff explaining what is going to happen to patients clearly so they can understand

Communication between hospitals and GPs

The coordination of care within and between departments and wards

41

% Neither/nor % Don‟t know

36

24

38

18

37

5 8 5 5

7

9

Net satisfied

12

9

7

7

13

20

+65

+43

+38

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Overall, three in four residents are satisfied with staff explaining what is going to happen to patients (77%), with two in five very satisfied (41%). This rises to four in five among recent inpatients or outpatients (81%). However, as we have seen, the qualitative research demonstrated that patients were more positive about the communication skills of some staff than others. Satisfaction falls to 62% for communication between hospitals and GPs, and to 55% for the coordination of care within and between departments and wards. It is again worth noting, however, that significant proportions of residents are unable to offer opinions on these aspects of care (for example, 20% say they don‟t know how satisfied or dissatisfied they are with the coordination of care within and between departments and wards). Inpatients tend to be more satisfied than residents in general.

51


Hospital communications and coordination: patient vs. public perceptions Q

And from what you know or have heard, how satisfied or dissatisfied are you with each of the following aspects of your local NHS hospital? Patients

Public

% very satisfied

Staff explaining what is going to happen to patients clearly so they can understand

46% 36% 28%

Communication between hospitals and GPs 20% 20%

The coordination of care within and between departments and wards

15%

Base: All inpatients or outpatients (1,857) British adults, all public (1,658); fieldwork dates 10th March – 14th April 2009

3.3.2 Staff views on co-ordination & communication The results of the staff survey are very similar to those of patients and the general public, with areas of relatively high patient and public dissatisfaction also the areas that staff are more likely to mention as in need of a lot or a fair amount of improvement. Two in five staff say that the coordination of care within and between departments and wards is in need of either a lot or a fair amount of improvement (41%), while just under one in three highlight the patient pathway in terms of continuity of care as needing improvement (30%).

52


Hospital communications and coordination: staff perceptions Q

Thinking about quality of care in your trust, please indicate whether each of the following areas is in need of no improvement, in need of a little improvement, in need of a fair amount of improvement or in need of a lot of improvement. Net % Don't know % A fair amount % A lot improvement % A little % No need for improvement % Not stated needed

Co-ordination of care within and between departments and wards

14

The patient pathway in terms of 11 continuity of care Explaining their care to patients clearly so they can 8 understand it Ensuring that government 5 targets are achieved

27

34

19

34

16

8

41

11

36

6

15

-5

5 +11

23

13 3 +36

19

20

4

25

4 +40

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

Particular groups of staff appear to place slightly different emphasis for improvement on communication within hospitals: 

those staff who have worked for the NHS for ten years or more, scientific, technical and therapeutic staff, and health care assistants and support staff are more likely than staff in general to feel that coordination of care within and between departments and wards is in need of a lot or a fair amount of improvement (47% and 59% respectively compared to 41% overall); and



the patient pathway in terms of continuity of care tends to be seen as an aspect in need of a lot or a fair amount of improvement by nurses and midwives compared to their counterparts in general such as doctors or consultants, management, admin, health assistants and ST&T (38% compared to 30%).

Age also plays a part in influencing the views of staff, with those staff aged 16-54 more likely than those aged 55 or over to feel that explaining their care to patients clearly so that they can understand it is in need of a lot or a fair amount of improvement (25% compared to 16%). As described previously, this group were also more negative about the time available for staff to spend with patients, and these two aspects appear to be linked.

53


3.4 Waiting times 3.4.1 Public and patient views on waiting times In the qualitative work, although waiting times were mentioned as having a degree of impact on the perceptions of quality of care, their influence was not viewed as defining one. Instead, it was often found that people expected to have to wait for treatment in hospital and as long as they were kept informed about this they tended not to mind. In addition, it was mentioned that other factors, such as the way they were treated by staff, was of far more importance. A good experience of these other factors would often negate any negative views caused by long waits. In a degree of contrast to the qualitative findings, residents in the survey are generally less positive about waiting times possibly because they have not had a direct experience and are therefore more reliant on hearsay and negative media coverage. While three in five are satisfied with the wait from referral until the date of the visit (59%), one in four are dissatisfied (25%). Similarly, approaching three in five are satisfied with waiting times while in the hospital (57%), but three in ten are dissatisfied (29%). Again, some residents donâ€&#x;t know about waiting times, although in smaller proportions (for example, nine per cent donâ€&#x;t know about waiting times from referral until the date of the visit). Patients tend to be more positive; two in three patients are satisfied with waits from referral until the date of the visit (67%) and three in five are satisfied with waits while in the hospital (62%).

54


Waiting times: public perceptions Q

And from what you know or have heard, how satisfied or dissatisfied are you with each of the following aspects of your local NHS hospital? % Fairly satisfied % Very dissatisfied

% Very satisfied % Fairly dissatisfied

Waiting times from when your GP or other healthcare professional refers you until the date of your hospital visit

Waiting times while in hospital, from the appointment time to the time you are actually seen

24

% Neither/nor % Donâ€&#x;t know

35

20

37

6

7

Net satisfied

14

11

9

+34

16

13

7

+28

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

This is corroborated by findings in the survey conducted for NHS West Midlands around patient experiences of planned care. A majority of patients were concerned about how long they would have to wait to receive treatment when they were first told they needed to see a specialist (54% across the region as a whole). However, despite being concerned about waiting times in advance, many patients were happy with the length of time they actually waited for treatment (77% in the West Midlands for those answering who had started treatment), while one in five thought they should have been treated sooner (20%). The improved waiting times in the system may take time to filter through to the general public as more and more people begin to experience them. The survey results show that communication issues are important in relation to waiting times. The results of the survey show that people are reassured about waiting times if staff explain what is happening in a way they understand (see section 5.2). 3.4.2 Staff views on waiting times The results from the staff survey follow a similar pattern to that seen for residents. Only one in ten staff (nine per cent) think that there is no need for improvement in outpatient waiting times in hospital. In contrast, three in ten feel that they need a lot or a fair amount of improvement, while one in four feel that waiting times between GP referral and date of hospital visit also needs a lot or a fair amount of improvement (24%).

55


Waiting times: staff perceptions Q

Thinking about quality of care in your trust, please indicate whether each of the following areas is in need of no improvement, in need of a little improvement, in need of a fair amount of improvement or in need of a lot of improvement. Net % Don't know % A fair amount % A lot improvement % A little % No need for improvement % Not stated needed

Outpatient waiting times while in hospital, from the appointment time to the time they are actually seen

11

Patient waiting times from when their GP or other healthcare professional refers them until the date of their hospital visit

9

18

34

15

33

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

56

9

14

23

4 +14

25

4 +23


3.5 Hospital environment and facilities 3.5.1 Public and patient views on the hospital environment Encouragingly, most residents appear to be positive about aspects of hospital cleanliness. Three in four are satisfied that their local hospital looks and smells clean (76%), and a similar proportion are satisfied with the state of hospital facilities (75%), including toilets and waiting areas. While inpatients and outpatients are equally as satisfied as others with the hospital looking and smelling clean, dissatisfaction with the state of facilities is somewhat higher among recent inpatients (20%, compared to a 16% average). Nonetheless, other surveys conducted for NHS West Midlands have demonstrated that the public view improving hospital cleanliness as the top priority for improvement for the local NHS. Hence, while a majority of the public are satisfied they still feel further improvement is needed10.

Hospital environment: patient and public perceptions Q

And from what you know or have heard, how satisfied or dissatisfied are you with each of the following aspects of your local NHS hospital? % Fairly satisfied % Very dissatisfied

% Very satisfied % Fairly dissatisfied The hospital is kept looking and smelling clean

35

The doctors and nurses washing or cleaning their hands between touching patients

33

The state of hospital facilities, such as toilets and waiting areas

32

The state of hospital equipment The facilities patients can access, for example TV, telephones and parking Levels of infection in the hospital, such as MRSA and C. difficile The quality of hospital food

% Neither/nor % Don‟t know

42 30

11

7

7 6 5

41

17 14

4 9

43

29 30 26 30

Net satisfied

7 4

6 6 3

7

18

9

14

10

12

7 4

+59

14

+61

23 17 14

+49

18 9

+60

+5

6

+9

20 25

+15

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

The results from the survey show that perceptions of hospital hygiene and infection rates are mixed. Although three in five are satisfied with doctors and nurses washing their hands (62%), many remain concerned about hospital infections such as MRSA and C. difficile. Just two in five are satisfied with the latter (40%), while just under one in three are dissatisfied 10

For the second year running “Cleanliness of hospitals” was cited by West Midlands residents as the aspect that is most important to improve (16% in 2009). West Midlands Annual Telephone Survey 2009, Fieldwork carried out by telephone, throughout the area bounded by NHS West Midlands, between 8 April and 17 May 2009

57


(31%). Satisfaction with the level of hospital infections is higher for those who have recently been inpatients (48% satisfied), as is satisfaction with doctors and nurses washing their hands (71%). It is still worth noting, however, that 28% and 14% of inpatients are dissatisfied with infection levels and hand washing respectively. Qualitative research conducted on perceptions of cleanliness and infection in hospitals might help to explain some of the findings in the survey. Most participants had heard of infections in hospitals, however were unable to tell what the level of infection was in local hospitals – high, average or low. Furthermore, participants were generally unsure of what they knew and what they needed to know about infections. In addition, those with no direct experience of hospitals were found to be the most fearful overall in regards to infection risk and cleanliness – this was felt to be due to the fact that their perceptions resulted from the media as they had nothing else to base them upon. I don’t really know anything about MRSA… I just joke around saying that I am going to the doctor and will come back with MRSA… I don’t know how we catch it…I think people staying in the hospital should know how they can catch it. Female, 18-35 years, Cleanliness Group Residents are relatively less happy about other aspects of the hospital environment. Just two in five are satisfied with the quality of hospital food (40%) and one in four are dissatisfied (25%), although it is worth noting that a significant proportion don‟t know (25%). Among inpatients, who are more likely to have eaten hospital food, over half of inpatients are satisfied (55%) and three in ten are dissatisfied (30%). Fewer than half of residents are satisfied with other facilities patients can access, such as parking (46%), while two in five are dissatisfied (41%). A similar proportion of those who have been inpatients are dissatisfied (40%), but satisfaction rises to half (50%). Patients in the qualitative groups also tended to be fairly negative about both the quality of the food in their local hospital. There was a common belief that services like food preparation and cleaning were being contracted out of the hospital and that quality had suffered as a result. There was also a perception that more could be done to help patients eat the food they were given.

58


It would be nice if the nurses actually made sure that you were capable of eating your meal and had something that you could physically eat and digest and help you with it. Female, 35-54, Patient

3.5.2 Staff views on the hospital environment Significant proportions in the quantitative staff survey showed some concern about the hospital environment. Around one in three staff highlight the state of hospital or clinic equipment (37%), the quality of hospital or clinic food (36%) and the state of hospital or clinic facilities (33%) as areas that need a lot or a fair amount of improvement. Slightly fewer staff members mention providing a pleasant environment (30%), how clean the hospital or clinic looks or smells (29%), the availability of single sex accommodation (30%) and hospital infection rates (19%) as areas where a lot or a fair amount of improvement is required.

Hospital environment: staff perceptions Q

Thinking about quality of care in your trust, please indicate whether each of the following areas is in need of no improvement, in need of a little improvement, in need of a fair amount of improvement or in need of a lot of improvement.

% A lot % A little

17

The quality of hospital/clinic food

19

The state of hospital/clinic equipment The availability of single sex accommodation The state of hospital/clinic facilities, such as toilets and waiting areas

13

16

12

20

Providing a pleasant environment

10

20

How clean the hospital/clinic looks and smells

9

20

Hospital infection rates

13

5

29

24

11 41

28

48

21 12

9

3 +5 8 3 +15

4

29

+7

17

4 3 +28

43

21

3 3 +33

45

20

3 3 +37

44

14

Net improvement needed

% Don't know % Not stated

% A fair amount % No need for improvement

14

16

5 +43

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

However, the perception that cleaning and food were of poor quality was strongly contested by some staff in the qualitative discussion groups. They talked about improvements that had

59


been seen in the food in response to feedback, as well as it being served hot and in a visually pleasing way by ward service officers. The views and priorities of staff seem to deviate from those of residents in general. Some of the aspects that residents were shown to be relatively dissatisfied with, such as hospital food, are also highlighted by staff as priority areas for improvement. However, this is by no means a consistent pattern. In contrast, other areas of relative public dissatisfaction, for example infection rates, are not seen by staff to be as much of a priority for improvement. This may link to greater staff awareness of recent improvements in infection rates. The survey reveals that staff are more concerned about factors such as the state of hospital equipment – again this is likely to be a result of staff‟s increased knowledge and use of such equipment.

3.6 Clinical treatment and standards 3.6.1 Public and patients‟ perceptions on clinical care It is interesting to note that the quality of clinical treatment was rarely considered in the patient and public discussion groups. They assumed that their treatment would be successful but felt unable judge the quality of this because they did not have sufficient knowledge and understanding of the clinical side of things. I think if you see a consultant, you take it for granted that they’re at the top of their game. Female, 18-34, Patient In line with this, a sizeable proportion in the quantitative research (44%) say they would find it difficult to judge how good their medical treatment was. Nonetheless, a similar proportion of residents (44%) disagree.

60


Quality of clinical treatment: patient and public perceptions Q

Please could you tell me the extent to which you agree or disagree with the following statement with regards to your local NHS hospital? I would find it difficult to judge how good my medical treatment was. No opinion Strongly agree

6% Strongly disagree

15%

19%

44% Agree

44% Disagree

29% Tend to disagree

Tend to agree

25% 6%

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Neither agree nor disagree Net agree: 0

Different groups of residents report different abilities to judge their medical treatment: 

Asian residents are a little more likely than white residents to say they would find it difficult to judge the quality of their medical treatment (+12 net agree compared to -1).

Older residents aged 65 and over are more likely to say they would find it difficult to judge the quality of the medical treatment (+11 net agree compared to * overall) 11.

Residents who do not speak English as a first language would also find it more difficult (+19 net agree compared to -1), suggesting that there could be some communication challenges.

Interestingly, half of those who would be critical of their local hospital say they would find it difficult to judge how good their medical treatment was (50%), compared with two in five of those who would advocate their local hospital (39%). This may suggest a link between being informed about clinical outcomes and satisfaction. The majority of patients and the public believe that their local hospital provides good quality clinical treatment – three in four think their local hospital provides safe care (75%) and two in three agree their hospital minimises any pain suffered by patients (66%). Encouragingly,

11

An asterisk is used to denote a number that is less than half of one percent but greater than zero.

61


those who have recently been inpatients, and so have first-hand experience of the clinical aspects of secondary care, particularly agree that their hospital minimises pain (73% agree).

Clinical treatment: patient and public perceptions Q

From what you know or have heard, to what extent do you agree or disagree with the following statements? % Strongly agree % Tend to disagree

Your local NHS hospital provides safe medical care for patients

Your local hospital minimises any pain suffered by patients

% Tend to agree % Strongly disagree

% Neither/nor % No opinion

31

44

29

37

8

Net agree

7

7 5 5

+62

7 6

14

+54

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Those aged between 45 and 64 are least likely to believe that their hospital provides safe care (71% agree, compared to 75% overall), while those aged 65 and over are particularly positive (79% agree). Ethnic minority residents are more likely than average to strongly agree the hospital offers safe care (39%, compared to a 31% average); this is especially positive, given that this group appears to place strong emphasis on the quality of clinical treatment when judging quality overall and is less positive on other overall ratings such as satisfaction and advocacy, as noted in the previous sections.

3.6.2 Staff perceptions on clinical care NHS staff are generally positive about the clinical treatment that patients receive in their hospitals. When asked about which areas need improving in their Trust, fewer than one in five staff members highlight providing safe care (16%) or minimising any pain suffered by patients (14%) as in need of either a lot or fair amount of improvement. More than three in five staff members feel that these aspects only need little or no improvement (66% and 62% respectively).

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Clinical treatment: staff perceptions Q

Thinking about quality of care in your trust, please indicate whether each of the following areas is in need of no improvement, in need of a little improvement, in need of a fair amount of improvement or in need of a lot of improvement. Net % Don't know % A fair amount % A lot improvement % A little % No need for improvement % Not stated needed

Providing safe care 5

11

Minimising any pain suffered by the patient 3 11

44

38

22

24

14

19

3 +50

5 +48

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

Clinical staff such as doctors, consultants, nurses and midwives display the most interesting results. Staff in these occupational groups are more likely than their counterparts to feel that minimising any pain suffered by the patients needs only a little or no improvement (73% of nurses and midwives and 79%12 of doctors and consultants, compared to 62% overall). While clinical staff are more positive than other staff members about pain minimisation, and the majority say there is only a little or no improvement needed when it comes to safe care (71%), nurses, midwives, doctors and consultants are more likely than staff generally to say a lot or a fair amount of improvement is required to ensure safe care (24% of these clinical staff vs.16% of staff generally). This may simply be a due to clinical staff being more directly involved and aware of potential safety issues than staff more generally. Length of service in the NHS also appears to hold an influence on the opinions of staff. Those staff who have been employed in the NHS for under ten years are more likely than those who have worked for the NHS for ten years or more to feel that providing safe care and minimising any pain suffered by the patient is in need of no improvement (27% compared to 18% and 28% compared to 21% respectively).

12

Please treat results with caution as they are based on a small number of people (89).

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Having explored current perceptions of meeting the quality standards expected of local hospitals, the next chapter focuses on the perceived barriers to providing excellent care.

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4. Perceived barriers to providing excellent care

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4. Perceived barriers to providing excellent care This chapter explores what patients, the public and staff feel are the barriers to providing excellent quality of care. While patients and the public were asked what they think makes it difficult for hospitals to deliver high quality of care, staff were asked what their Trust could do to make it easier to deliver better quality care.

Summary One of the most commonly mentioned barriers to providing excellent quality of care is perceived under-staffing, often linked to a perceived lack of resources. Among patients and the public, a majority agree their local hospital does not have enough staff, and this is generally attributed to staff looking busy when people used the service as a patient or visitor. Those who have been inpatients, or who have visited someone else in hospital, are particularly likely to raise under-staffing as a barrier. In the qualitative research, staff also mentioned staffing as a barrier to providing high quality care. All three audiences also felt that a key barrier to providing excellent quality of care is a lack of leadership. Patients and the public often spoke about “bringing back the matrons�, while staff felt that some of the difficulties around resourcing could be eased by good management. The research emphasises the importance of effective and visible leadership for all three groups. Greater communication and involvement of staff in decision-making is a potential area that staff say would make it easier for them to deliver a better quality of care. The quantitative research shows that this is more important for them than reducing financial or resource constraints or better leadership.

4.1

Resources and staffing

Insufficient resources were a commonly mentioned barrier to providing excellent quality of care in all the discussion groups. This reinforces the findings of the literature review, which emphasises perceptions of staffing levels as an important driver of perceptions of quality of care13.

13

Department of Health (2007) Public Perceptions of Privacy and Dignity in Hospitals

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The perception that wards were understaffed was held by almost all participants in the patient and public discussion groups, many of whom based their assumptions on the numbers of nurses they had observed on the wards, as well as the regular media coverage of this issue and what they had heard from NHS staff (both when in hospital and when they had families or friends who worked in the NHS). I think the NHS is understaffed anyway, and the quality that they’d like to give, they can’t give it because they just don’t have the manpower. Female, 18-34, Patient

When asking about the barriers to providing high quality care in the quantitative research, the top ten responses clearly reflect these qualitative findings, with the two most frequent responses being financial constraints (38%) and understaffing (28%).

Barriers to high quality of care: patient and public perceptions Q

What, if anything, do you think makes it difficult for hospitals to deliver high quality of care? TOP TEN MENTIONS

38%

Financial constraints/resources/money

28%

Under-staffed (unspecified) Government targets

8%

Too many patients/amount of patients

8%

Not enough nurses Patients being uncooperative/ill mannered/rude/demanding Not enough doctors Overload of paperwork/use of computers/too much administration Staff need more academic/practical training/expertise/understanding Poor/bad/little hospital management

7% 4% 4% 4% 3% 3%

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Exploring this further, three in five believe their local NHS hospital lacks staff, such as nurses (60%). Approaching two in five strongly agree with this notion (37%). Over half agree that hospital staff do not have much time to speak to patients (53%), which the qualitative research suggests may contribute to perceptions of understaffing.

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Staffing levels: patient and public perceptions Q

Please could you tell me the extent to which you agree or disagree with the following statements with regards to your local NHS hospital? % Strongly agree % Tend to disagree

% Tend to agree % Strongly disagree

My local hospital does not have enough staff, such as nurses

I donâ€&#x;t think hospital staff have much time to talk to me

37

% Neither/nor % No opinion

23

24

28

6

6

13

22

Net agree

7

+41

14

14

5

+16

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Linking in with the findings from the qualitative research, inpatients and those who have visited someone in hospital in the past year are more likely to think their hospital lacks staff (66% agree among both groups). Given that patients and the public are unlikely to have access to detailed information on staffing ratios, it is important to look at what is driving perceptions. The chart overleaf suggests that perceptions of understaffing may be linked to the way staff appear to patients, or to other issues (such as waiting times). Those who agree that their hospital does not have enough staff attribute this to staff looking busy when they were a patient or a visitor (46%). One in ten also believe there are not enough staff because of long waiting times (12%).

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Reasons for perceived inadequate staffing levels: patient and public perceptions Q

You said that your local hospital does not have enough staff. Why do you say that? Staff looked busy when I was a patient/visitor

TOP TEN MENTIONS

46%

Understaffed/not enough staff/shortage/staff not around (doctors/nurses) Long waiting times/queues/appointment times I have heard from other people (not working in the NHS) that staff look busy

8%

I heard about it through the media

8%

18% 12%

Not enough time with patient or doctor

3%

Budget/financial problems/funding/cutbacks

3%

Do not provide/lack of care/attention Asking staff to do too much/too much work/paperwork/under pressure/tired staff More specialist staff needed/qualified staff/not the right specialist available,/trainee staff

2% 2% 2%

Base: All who agree that their local hospital does not have enough staff (2,136); fieldwork dates 10th March – 14th April 2009

It is therefore likely that hospitals can improve residents‟ perceptions of staffing levels, by tackling related issues such as the organisation of staff time and the dedicated time staff have to deal with patients. Staff also felt that staff resources were an issue which sometimes affected the care they were able to provide, particularly during the winter months when wards tended to be busier. Staff felt that if staffing levels were not high enough there was a double impact on quality: 

the impact that continuously feeling over-worked and under-valued was likely to have on staff morale and, hence, the motivation to provide excellent care; and

physically having the time to provide high quality care.

However, as mentioned above, good leadership was a commonly mentioned solution to these issues. Some staff also felt that the shorter lengths of time patients spent in hospital made it more difficult to build up a good relationship with them and provide excellent care.

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They closed the, shorten the hospital stay, with a hip it’s, they’re now in two or three days, where it was a week, so you've got a short time to get everything done to get them out. Staff member

4.2

Effective and visible management

Patients, the public and staff in the qualitative groups felt that providing excellent quality of care required excellent leadership, both at ward level and from senior management. The perceived lack of such leadership was a commonly mentioned barrier to meeting the defined quality standards. Patients and public often lamented the loss of matrons, and had very little awareness of how wards are currently managed. The lack of visible management led them to believe that there was no one to take responsibility for issues arising on a ward and little accountability if mistakes were made. You’re only as good as your leader, aren’t you? Whatever you do it filters through, filters down the line doesn’t it, with leadership? Female, 18-34, Patient

Discipline used to be strict. You used to have a matron and nurses were checked every day. Used to make sure that the uniforms were crisp and their hats were right. Male, 18-34, General Public

This also emerged from the qualitative research around hospital cleanliness. Participants said they would feel reassured if someone took the responsibility of ownership for maintaining standards. It was felt that the presence of matrons in wards, nurses taking a pro-active role in ensuring cleanliness was maintained, and patients being given power to support a clean environment (for example, by understanding their role) were all important factors. Matrons were felt to be important as they were perceived as having responsibility for individual wards – it was this concept of localised cleanliness management that was thought to be most effective at ensuring standards were met. Participants in the staff discussion groups also stressed the importance of good management at ward level and reported that, where this was lacking, providing good quality of care could be very difficult (because poor management meant that resources were poorly allocated and

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formal procedures were sometimes ignored). For some, it was also about a leader placing the right level of importance on quality of care and driving improvements. If you hadn’t got someone who’s really interested in quality I don’t think it would be on the agenda. Staff member It is interesting to note that improved leadership in the Trust, or in the ward or team, are only cited by 17% of staff in the staff survey, as something which would help them to deliver better care. However, leadership is clearly central to all the other issues which staff cite as barriers.

4.3

Communication and involvement

When asked how their Trust could make it easier for them to deliver a better quality of care, the top mentions of NHS staff were more communication and involvement of staff in decision making (40%). This is cited more frequently by staff than the most popular issues emerging in the patient and public research of fewer financial or resource constraints and better leadership at ward or team (19%, 16% and 15% respectively).

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Ways to improve quality of care: staff perceptions Q

Which TWO or THREE of the following, if any, do you think your trust could do to make it easier for you to deliver a better quality of care?

More communication and involvement of staff in decision making

40%

Less paperwork and meetings

32%

Less focus on Government targets

26%

Reducing the time spent on non-appropriate tasks

25% 21%

Improvements in staff training Fewer financial or resource constraints

19%

Making systems and processes on wards or departments more efficient

16%

Better leadership in my ward or team

16%

Better leadership in the trust

15%

Better definition of roles and responsibilities

15% 13%

Greater levels of investment in the latest technology

9%

A higher standard of equipment More information on the feedback from patients about the quality of care that they receive

8%

More information on the quality of care delivered by my ward or team More focus on Government targets

7% 1% 6%

Other

2%

Donâ€&#x;t know Nothing would make it easier

* 2%

Not stated

Base: All staff members (1,030); fieldwork dates: 24th April - 8th June 2009

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Discussions in the qualitative groups demonstrated that some staff felt that some senior managers in hospitals did not fully understand the realities which staff experienced on the front-line and did not properly involve clinical staff in decision making.

It used to be clinicians ran the system.

Clinicians are now

pawns in the system… they can see rational things to do but they’re not involved in the decision making process. Staff member This issue is explored further in the following chapter.

4.4

Other barriers

Paperwork and meetings (32%), and government targets (26%) were some of the top barriers mentioned in the staff quantitative survey. Again, these are linked with the staffing and management issues discussed in this chapter. Doctors and consultants are more likely to mention less focus on government targets as a means of improvement than other occupational groups (46%14 compared with 26% overall), as are people who have worked in the NHS for over ten years (33%) and those aged 55 and over (35%). These issues were also raised in the patient and public discussion groups:

The things that make it difficult are governmental targets, the false imposition of waiting list initiatives and timescales. Staff member

I think it tries very hard to do that but I think it’s under an awful lot of targets that it has to meet, make a big difference to it, and also financial restrictions. Staff member Quality of care is the priority, but they’re under such pressure all the time that it’s virtually impossible for them to deliver it properly. Male, 18-34, General Public 14

Please treat results with caution as they are based on a small number of people (89).

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Another difficult barrier to overcome was thought to be the initial design and infrastructure of the hospital itself. Many of the hospitals discussed were old buildings, with high ceilings (that were difficult to clean) and inappropriately shaped rooms (that could prevent nurses from overseeing an entire ward at any one time). The environment isn’t exactly what you would want in 2009, so there’s not peace and quiet, there isn’t a huge amount of privacy. Staff member

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5. Quality at the heart of the NHS

75


5. Quality at the heart of the NHS We have already looked at how patients, the public and staff define quality, and whether they think their hospital is providing excellent care. This chapter goes on to explore whether patients, the public and staff think quality is the top priority for their local NHS services, along with possible practical measures that hospitals could take to reassure them that quality is the top priority.

Summary The majority of patients, the public and staff feel that their hospital does place quality of care as their top priority, with many staff feeling that it has actually become a greater priority over the last two years. However, there are also thought to be competing priorities for the NHS, with financial concerns and government targets commonly mentioned in the qualitative research. This applied to all three audiences – with staff sometimes feeling they provided good quality of care despite these constraints. Some also felt, as did patients and the public, that while quality was their top priority, this goal was not always achieved. The general public and patients, and to a lesser extent staff, appear to distinguish between different hospital employees in their commitment to quality of care. While clinical staff are viewed as being on board, residents are more sceptical about the priorities of management staff and those not on the front line, who they are less familiar with. While staff are more positive about senior management, still only just over half say that senior managers where they work are committed to improving the quality of patient care. They are fairly negative in their assessments of communication between senior managers and front line staff. For the general public the biggest factor in forming their views, whether they are positive or negative on this aspect, is their own personal experience. While for the majority this is framed by the clinical care that they receive, it also includes aspects such as waiting times and the treatment and care received from staff. This again highlights the importance of providing a positive experience for patients when they come into contact with the service, and the likely impact on reputation that this will have if they do not.

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Regression analysis on the results show us strong associations between respondents‟ opinions on whether quality is their hospital‟s top priority and their answers to other questions in the surveys. For all groups, perceptions about whether the hospital delivers safe medical care, minimises pain, and whether there is effective communication and co-ordination are important drivers of their views on quality. In terms of reassuring patients and the public that quality is a top priority, key areas that could be addressed are visible leadership, demonstrable continuous staff training and development (including in “customer care”), evidence of cleaning schedules, being more proactive in gathering and acting on feedback, good handover of care, and staff having more time to spend with patients. To reassure staff that quality is a top priority, many of the findings are focused around improved communication. There is a sense that clearer messages around quality from managers would help, as would being able to share ideas about improving quality with colleagues and generally being able to make suggestions for improvement.

5.1 Perceived priorities of the NHS 5.1.1 Patient and public views on hospital priorities The quantitative research demonstrates that most West Midlands residents feel that their local hospital puts high quality of care as its top priority. In order to test people‟s views on this fully we asked about it twice – first at the start of the interview, and then again towards the middle. When asked initially (at Q1), before any other questions about the NHS and their local hospital, around seven in ten agreed that their local hospital puts high quality of care as its top priority (68%), and fewer than one in five disagreed (18%). As the chart below demonstrates, when asked again later in the survey, following further questions about the different aspects of quality (at Q13), three in four agreed that quality was the top priority (75%). This suggests that simply engaging people in thinking about quality in relation to local NHS services, may help to reassure them.

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Priority of quality of care: patient and public perceptions Q

To what extent do you agree or disagree that your local NHS hospital… % Strongly agree % Tend to disagree

Q1: puts high quality of care as its top priority

Q13: overall puts high quality of care as its top priority

% Tend to agree % Strongly disagree

28

% Neither/nor % No opinion

40

33

Net agree

9

42

9

9

8

9

6

+50

6 4

+60

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Looking at initial perceptions (Q1), agreement is most common among older people, with 72% of those aged 65 and over agreeing that quality is a top priority (compared to 68% overall) and 42% strongly agreeing (compared to 28% on average). Conversely, those with caring responsibilities and people who have visited A&E services in the past 12 months are somewhat more likely than average to disagree (22% for both, versus 18% overall). Patients are more strongly positive about their hospital‟s top priority, with one in three strongly agreeing that the priority is quality (33%). Residents‟ positive perceptions of hospital priorities are based on personal experience. Among those who strongly agree that high quality is a top priority for their local hospital, 42% say this because they have had a good/satisfactory experience, 22% talk about an excellent service, and a further 11% also say this is due to personal experience.

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Reasons for perceiving high quality of care as a priority: patient and public perceptions Q

Why do you say that [you strongly agree that your local NHS hospital puts high quality of care as its top priority]? Good/satisfactory experience/service/ treatment/no problems/complaints

TOP NINE MENTIONS

42%

Excellent/first-class/quality/ service/ care/treatment

22%

Through/from personal experience

11%

Positive staff mentions

8%

Promptly/efficiently/quickly seen to/received treatment

7%

Staff responsive in looking after/taking care of patients

6%

Through/from family/friends/ other people‟s experience

6% 4%

Hospital is clean/sterile Well informed/contacted frequently by the NHS

2%

Base: All who strongly agree that their local NHS hospital puts high quality of care as its top priority (972); fieldwork dates 10th March – 14th April 2009

Looking instead at the people who strongly disagree that quality is a top priority, this again tends to be based on past experience, but this time experiences that were disappointing (31%). An additional one in ten mention personal experience (12%). Also influencing negative perceptions are waiting times and inconvenient appointments/cancellations (18%), a lack of patient care (16%) and other people‟s experiences (14%).

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Reasons for not perceiving high quality of care as a priority: patient and public perceptions Q

Why do you say that [you strongly disagree that your local NHS hospital puts high quality of care as its top priority]? Bad/disappointing experience/service/treatment Lack of/inconvenient appointments/long waiting lists/queues/cancellations

TOP TEN MENTIONS

31% 18% 17%

Do not provide/lack of patient care Through/from family/friends/ other people‟s experience

15% 12%

Through/from personal experience Shortage of staff/need more staff

7%

Hospital is not clean/low standards of hygiene Bad press coverage/TV news/newspapers

7% 7% 6%

Negative staff mentions Bad/lack of/problems with hospital management/supervision/organisation

5%

Base: All who strongly disagree that their local NHS hospital puts high quality of care as its top priority (286); fieldwork dates 10th March – 14th April 2009

The discussion groups held with patients and the public shed extra light on these findings. They revealed that people did not feel very informed about local NHS‟s priorities and therefore found it hard to comment on them. While initially there was general consensus that the main priority of the NHS was to make people better, on further reflection other conflicting priorities such as finances and government targets were highlighted. These were often thought to take precedence over patient care. People mentioned stories they had heard in the media about patients not having access to certain drugs or treatments because they were too expensive, or wards being under-staffed due to limited funds. I think most of it’s the money isn’t it? You see on the news that people can’t have medication because the money which would make their life longer. Female, 35-54, Patient

It’s probably money, isn’t it? It all comes down to money. Female, 18-34, Patient

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The survey results show that when the public engage in thinking through issues around quality and NHS services, they tend to be more positive. Hence, a finding of this research is the need for greater engagement with the public and patients around quality, otherwise people are more likely to rely on stories they hear in the media in forming their views.

5.1.2 Key drivers of public and patient views on prioritising quality In order to analyse in more detail whether or not people think quality is a top priority for their hospital, we conducted a regression analysis. The aim of this analysis is to look behind the data at correlations in respondentsâ€&#x; answers to questions, taking other answers into account. It isolates factors that are strongly and independently related to people thinking quality is a top priority. The results presented here therefore identify factors associated with high odds of agreeing that their Trust places high quality care as its top priority. The results should not be interpreted as indicating a causal link, as we could not say that any of these factors cause someone to think that quality is prioritised, but that there is a strong association between the two. The table overleaf presents those factors which make a respondent more likely to agree that their local hospital places quality of care as its top priority. The higher the odds ratio (OR) for a particular question, the more likely people are to agree their local hospital places quality of care as its top priority. An OR of greater than one implies an increase in the likelihood of agreeing, while an OR of less than one indicates a decrease in the likelihood of agreeing. More details on how to interpret the regression results can be found in Appendix 3.

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General public

Patients

Visitors

– are more likely to think that their local hospital places quality as its top priority if they…

– are more likely to think that their local hospital places quality as its top priority if they…

– are more likely to think that their local hospital places quality as its top priority if they…

Work in the NHS (OR=4.79)

Agree that their local NHS hospital provides safe medical care for patients (OR=1.77)

Agree that hospital nurses have high quality of care as their top priority (OR=1.60)

Are satisfied with the overall quality of care provided by their local NHS hospital (OR=2.09)

Agree that their local NHS hospital minimises any pain suffered by patients (OR=1.45)

Agree that their local NHS hospital minimises any pain suffered by patients (OR=1.49)

Agree that their local NHS hospital provides safe medical care for patients (OR=1.79)

Have attended hospital as an outpatient (OR=1.44)

Are satisfied with the overall quality of care provided by local NHS hospital (OR=1.43)

Are satisfied with the aftercare patients receive once they have finished their treatment (OR=1.42)

Are satisfied with the hospital being kept looking and smelling clean (OR=1.24)

Are satisfied with receiving a good outcome from the care (OR=1.38)

Are satisfied with the friendliness of staff (OR=1.33)

Are satisfied with waiting times from when their GP or other healthcare professional refers them until the date of their hospital visit (OR=1.20)

Are satisfied with the amount of involvement patients have in decisions about their care (OR=1.34)

Agree that senior managers have high quality of care as their top priority (OR=1.31)

Agree that the quality of care that they see other patients receiving will affect their rating of their overall experience (OR=1.19)

Agree that patients feel in control of their own care (OR=1.25)

Are satisfied with the communication between hospitals and GPs (OR=1.29)

Are satisfied with the friendliness of staff (OR=1.19)

– and are less likely to think that their local hospital places quality as its top priority if they…

Are satisfied with the coordination of care between departments and wards (OR=1.18)

Have no children under 16 in household (OR=0.55)

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It is evident that there are some differences between key drivers for the general public, patients and visitors. However, perceptions around safe medical care, minimising pain, and effective communication and co-ordination are important drivers for all groups.

5.1.3 Staff views on hospital priorities The majority of NHS staff feel that their Trust places high quality care as its top priority, with two in three agreeing (66%) and fewer than one in five disagreeing (18%). These are very similar proportions to those indicating whether or not West Midlands residents think that their local hospitals rate high quality care as their top priority.

Priority of quality of care: staff perceptions Q

To what extent do you agree or disagree with the following statement? My trust places high quality care as its top priority Donâ€&#x;t know

Not stated

Strongly disagree 18% Disagree

Strongly agree

2% 5%1%

Tend to disagree

22%

66% Agree

13% Neither agree / nor disagree

14%

Tend to agree

44%

Net agree: +48

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

Those who have seen information on quality of care are significantly more likely to strongly agree that the Trust they work for places this as its top priority than those who have not seen such information (30% compared with 13%). This does suggest a link between being informed about quality and feeling that the hospital is prioritising quality in its work. Again, newer members of staff are more likely to be positive than staff who have worked in the NHS for a longer period of time. Staff who have worked in the NHS for under two years are significantly more likely than longer-serving staff to strongly agree that the Trust they work for places high quality care as its foremost priority (35%, compared with 21% of staff who have worked for the NHS for ten years or more).

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Encouragingly given the new focus on quality, just over half of West Midlands staff think that quality of care has become more of a priority over the last two years (51%), while around one in six think it has become less of a priority (17%). Around one in five think that it has remained the same (21%).

Change of prioritisation of quality of care: staff perceptions Q

From what you know or have heard, over the last two years or so, do you think quality of care has become more or less of a priority for your trust? Not stated

Donâ€&#x;t know

8% Less of a priority

3%

17% 51%

It hasnâ€&#x;t changed much

More of a priority

21%

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

As we may expect, recognition by staff that quality of care has become more of a priority for a Trust correlates with satisfaction levels with the quality of care delivered. Staff who are satisfied with the quality of care administered are more likely to think that it has become more of a priority than those who are dissatisfied (63% compared with 19%). Similarly, those who would speak highly of their Trust are much more likely to think quality of care has been more highly prioritised than those who would criticise their Trust (70% compared with 17%). This suggests the importance that staff place on quality in their overall judgement of the Trust.

5.1.4 Key drivers of staff views on prioritising quality As with the results from the survey with local residents, the results of the staff survey were analysed using logistic regression to identify the factors which make it more likely that staff will feel that their Trust places high quality of care as its top priority. The factors in the table below are associated with staff being more likely to agree that quality is the top priority for their Trust. As with the general public and patients table, the higher the odds ratio (OR) for a particular question the more likely staff are to agree their Trust places high quality care as its

84


top priority. An OR of greater than one implies an increase in the likelihood of agreeing, while an OR of less than one indicates a decrease in the likelihood of agreeing. More details on how to interpret the regression can be found in Appendix 3.

Staff – are more likely to think that their hospital places quality as its top priority if they…

But are less likely to think that their hospital places quality as its top priority if they…

Are satisfied with the overall quality of care patients receive in their Trust (OR=3.31)

Have worked in the NHS for ten or more years (OR=0.30)

Agree that senior managers are committed to improving the quality of patient care (OR=2.07)

Have worked for the NHS for more than five years but less than ten years (OR=0.40)

Agree that everyone in the organisation actively contributes to good quality patient care (OR=1.30)

Once again this emphasises the importance for staff of feeling that managers are committed to improving quality and feeling that everyone works together.

5.1.5 Frontline staff priorities versus senior management priorities Patients and the public perceive priorities to differ between different types of hospital staff, with people tending to be more positive about frontline and clinical staff. Although over four in five agree that nurses (83%) and doctors/consultants (82%) have quality of care as their top priority, just three in five say the same thing about non-clinical staff, such as caterers, porters and cleaners (62%) and less than half (42%) think hospital senior management has quality as a top priority. Having said this, levels of awareness about non-clinical staff and senior management are lower, presumably because residents have less interaction with them (13% and 25% respectively say they don‟t know).

85


Putting quality of care at the heart of the NHS: patient and public perceptions Q

To what extent do you agree or disagree that the following people at your local NHS hospital have high quality of care as their top priority? % Tend to agree % Strongly disagree

% Strongly agree % Tend to disagree

Hospital nurses

46

Hospital doctors and consultants Staff who are not medically trained, such as caterers, porters and cleaners Senior management at the hospital

% Neither/nor % No opinion

37

43

39

23

14

39

28

10

12

11

10

Net agree

5 435

+76

6 435

+75

10 5

13

25

+47

+20

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Inpatients, the group most likely to see non-medical staff at the hospital, tend to be the most positive about them, with 70% agreeing that non-medical staff put quality of care as their top priority (compared to a 62% overall). Interestingly, patients do not seem to hold doctors, consultants and nurses in any higher esteem than the general public – they are highly thought-of across all residents. West Midlands staff generally think that senior managers in their Trusts are committed to improving the quality of patient care, with over half agreeing that they are (56%), and just under one in six disagreeing (15%). This is a more positive view than patients and the general public have, one in five of whom think senior managers do not have high quality care as their top priority (21%). However, staff perceptions of senior management communication and engagement with front line staff are more negative. Only just over one in three staff agree that communication between senior management and front line staff is effective (35%) and the same proportion disagree. Similarly, fewer than three in ten agree that senior managers try to involve front line staff in important decisions (28%), while approaching two in five staff disagree with this statement (38%).

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Management priorities: staff perceptions Q

To what extent do you agree or disagree with each of the following statements about the general and clinical management at your trust? % Strongly agree % Tend to disagree

% Tend to agree % Strongly disagree

Senior managers where I work are committed to improving the quality of patient care

22

Communication between senior management and front line staff is effective

8

Senior managers at my trust try to involve front line staff in important decisions

8

% Neither/nor % Don't know

34

26

% Not stated

19

22

20

23

10 5 7 2 +41

23

22

Net agree

13

17

52

-1

8 3 -11

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

Looking in more detail, people who have worked in the NHS for less than two years are more likely than those who have worked there for more than ten years to think that their senior managers are committed to improving quality of care (70% compared with 53%). Staff who have been working for the NHS for less than two years are also more likely to agree that communication is effective than those who have been working there for more than 10 years (45% agree compared with 30%). This is in keeping with the more positive attitude newer members of staff display throughout the survey when compared with longer-serving staff members. In line with the survey findings, almost all staff in the qualitative discussion groups felt that there was a distinct difference between the priorities of front-line staff and those of senior management. They felt that senior management knew little about how the hospital was run on a day-to-day basis and often set targets or allocated resources inappropriately, which in turn had a detrimental effect on the quality of care that front-line staff were able to achieve. They’re not on the wards day-to-day basis, each ward is different we know what’s going on, it’s different being up there than down there. Staff member

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My feeling is that their priority is to do what they’re told, to tick boxes, to deliver on targets. Staff member

5.2 Reassuring people that quality is the top priority 5.2.1 Reassuring patients and the public In the discussion groups patients and the public were asked what would help to reassure people that quality was at the heart of the work of their local hospital. They were then asked to identify some practical steps which a hospital might take to improve perceptions. These suggestions were then tested out in the quantitative survey. 5.2.1.1 Perceptions of staffing levels When the discussion group participants were asked what would reassure them that excellent care was the priority in their local hospital, seeing more nurses on the wards was the most common answer. As we have discussed, the perception that hospital wards and departments were understaffed was a deep-seated one, and many patients felt that seeing more staff on the wards would help to reassure them. They felt that improved staffing levels would result in happier, friendlier and more motivated staff, with more time to spend with patients. I think staff morale will play a big part on the quality of care. I think if the staff are fed up then it’ll probably show. Male, 18-34, General Public

People first, cost second. If, to save somebody’s life it costs so much money, then that’s what they, we should be having to pay. Male, 18-35, General Public

There was a widely held belief that the staff structure was “top heavy” and that more efforts should be made to reallocate resources to the front line.

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I think a lot of the money is going into the business end, the management side, and not enough to the grass roots, and if there was more money going into the grass roots, it would attract more people, and maybe more nurses, and that's what they desperately need. Female, 55+, Patient

However, as noted earlier, the view that there is not enough staff seems to be linked to the fact that staff look busy and patients want more time with them. Hence, reassuring people that quality is the top priority, means addressing the underlying reasons behind perceptions of understaffing. As two in three residents agree that if they have questions, they would appreciate answers from any member of staff, not solely doctors (65%), training other staff members to respond to simple queries might therefore alleviate the feeling that staff do not have time to talk to patients and tackle perceptions of understaffing. However, three in ten disagree that they would want any member of staff to answer (28%), suggesting that a significant minority will only be satisfied if their questions are answered by senior medical staff. 5.2.1.2 Clearer and more visible leadership Patients and public in the discussion groups agreed that visible leadership would help to reassure them that quality was a central priority. Many wanted to see a ward sister (or matron) who was responsible for everything on their ward and accountable if things were found to be below the defined quality standards. The research demonstrates that, on the whole, patients do not fully understand current ward management structures and are not aware that matrons exist. Would they not have someone that’s sort of overseeing everything like this that they could say, well, matron, this has been a problem here, then she would delegate. Male, 55+, patient The results from the quantitative survey also highlight this factor as respondents felt that having a clearly identified leader in each ward or department would be the most important thing a hospital could do to improve the quality of patient care (see chart on page 92).

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5.2.1.3 Staff skills Continuous staff training and development was also discussed in relation to excellent care. This was in relation to clinical expertise as well as the communication & empathy skills discussed earlier in the groups. While many felt that people skills, such as friendliness and treating people with respect and compassion should come naturally to staff, they also agreed that working with staff on these areas would ensure that they remained prominent. Staff being friendly and greeting patients with a smile was thought to be an easy and cost free way of improving quality of care in the NHS. It was felt that, for the most part, this was already happening but participants felt that there was still room for improvement (particularly during busy periods when such considerations tended to be forgotten, and among some of the more senior staff). It doesn’t cost any money to change how you’re treated and how you’re spoken to. Female, 35-54, Patient

5.2.1.4 Waiting times The discussions in the qualitative groups highlighted the fact that waiting times within the hospital are an important factor in determining people‟s perceptions of the quality of patient care. However, findings from the research show that concerns around waiting times are also connected with communication issues and the way they are treated by staff. The survey shows that around nine in ten residents agree they do not mind waiting to be seen if they receive eventually receive high quality care (88%), while a similar proportion do not mind waiting if they receive an explanation (86%). 5.2.1.5 Other factors More visible cleaning schedules, showing the time that a ward was last cleaned and requiring a signature from the person who had cleaned it, were also thought to be easy to implement. Patients and public felt that seeing evidence of when a ward was last cleaned, as well as the name of the person accountable for this, would help to alleviate their concerns about ward cleanliness. Patients and public also felt that hospitals should be more proactive in obtaining feedback from patients and showing that this is being taken seriously. Some suggested the use of feedback forms, similar to those provided in restaurants or hotels, allowing patients to rate

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particular aspects of their stay (including the friendliness of staff and the cleanliness of the ward). Moreover, it was felt that this feedback should be visibly acted upon – perhaps by posting responses to it on ward notice boards. Giving out people questionnaires and see how you feel, and maybe putting up things in the hospitals saying, we asked you and you told us this, and this, and then what they need to improve on… maybe, say, well, from last year, we’ve improved on this, or that. Female, 18-34, General Public

As already mentioned, when making judgements about quality, patients and visitors also take into account the ways they feel other patients are being treated. This is reinforced in the survey results, as two in three agree that when assessing their overall experience, they would take into account the quality of care that other patients receive (66%). Hence, demonstrating quality involves demonstrating that high quality care is given to all.

Quality of other people’s care: patient and public perceptions Q

Please could you tell me the extent to which you agree or disagree with the following statement with regards to your local NHS hospital? The quality of care that I see other patients receiving would affect my rating of my overall experience even if the care I personally received had been high quality.

No opinion Strongly disagree 24% Disagree

Strongly agree

5% 9%

28% Tend to disagree

Neither agree nor disagree

66% Agree

15% 5% 37%

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

91

Tend to agree Net agree: +42


5.2.1.6 Practical steps to reassure people Participants in the discussion groups were asked to identify practical steps that a hospital might take to improve the quality of patient care. Their suggestions were then tested in the quantitative survey. From the chart below, we can see that all the suggestions are generally considered to be important in improving the quality of care. Among the most important practical measures that hospitals can implement are having clear identified leaders in wards and departments (with a mean score of 8.81 out of 10), making it clear that staff are informed about the care needs of each patient (8.65 out of 10) and spending more time telling patients what to expect/answering their questions (8.57 out of 10). As suggested earlier in this section, the latter does not necessarily need to be time spent with doctors, but might be with more junior staff.

Measures to improve quality of care/ perceptions of quality of care: patient and public perceptions Q

On a scale of 1 to 10, where 10 is „very important‟ and 1 is „not important at all‟, how important do you think each of the following are in improving the quality of patient care? MEAN SCORE Having a clear identified leader, such as a senior nurse, in each ward or department

8.81

Staff on any shift or any ward will be fully informed about my treatment and care needs as a patient

8.65

Spending more time talking patients through what to expect and answering any questions

8.57 8.19

Training staff in customer care Collecting feedback from patients as they finish treatment, acting on any comments and telling people about this

8.04

Providing information about the roles and responsibilities of the people who will be caring for you

7.97

Putting clearer processes in place for patients to give anonymous feedback and comments on their experience in the hospital Putting more cleaning schedules up in hospitals so patients and visitors can see when areas were last cleaned

7.72 7.63

Giving patients a welcome pack so they know what to expect

6.94

Seeing senior managers talking to patients

6.93

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Across all these potential measures, there are some general demographic trends. Women tend to be more enthusiastic about each measure than men. Those from less affluent backgrounds also tend to rate each measure as more important than the average resident. Finally, importance often rises with age, with older people generally rating the measures higher than other age groups. In addition, there are more specific differences that emerge. Asian residents rate training staff in customer care as more important than the average (8.47 versus 8.19). Those who

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have visited others in an NHS hospital recently are keener on having hospitals collecting feedback from patients (8.21 out of 10 versus 8.04 overall). Furthermore, inpatients are more enthusiastic about certain measures than average, including training staff in customer care (8.43 out of 10 versus 8.19), having clear processes for anonymous feedback (7.90 out of 10 versus 7.72) and having welcome packs for patients (7.17 out of 10 versus 6.94). These particular measures are therefore more supported by those they most affect.

5.2.2 Reassuring staff 5.2.2.1 Priorities for staff While all staff in the discussion groups felt that quality was a top priority for them, they felt that clearer messages about quality (from both line managers and senior management) and managers showing their commitment to quality, would be most likely to reassure them that quality was a top priority for their hospital as a whole. These messages were about managers demonstrating that quality was central to their daily jobs and important to them. For example, one staff member described someone from the senior management team visiting all areas of the hospital and meeting frontline staff. This had raised his confidence in senior management and engendered the belief that they were in touch with the hospital, even if they were removed from the day-to-day running of the wards. Although staffing issues were mentioned in the staff groups, effective management was also felt to be important, as well-managed wards were seen as better able to cope with busy periods. The quantitative research echoes these findings and suggests that more interaction with managers would help to reassure staff that their Trust values quality of care. When asked about aspects of services and jobs that could be improved to demonstrate to them that their Trust puts quality of care at the top of its priorities, the most popular areas are increasing communication between managers and front line staff (49% strongly agree) and increasing the amount of time spent by senior managers with front line staff in their ward or department (45% strongly agree). Freeing up more time for staff to talk to patients and making quality a more important part of staff training were the next most popular choices, both with 39% of staff strongly agreeing with these measures.

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Reassuring staff that quality of care is a top priority: staff perceptions Q

To what extent, if at all, do you agree that improving each of the following would show you that your trust puts quality of care at the top of its priorities? % Strongly agree % Tend to agree % Tend to disagree % Strongly disagree % Not stated Increasing the communication between managers and front-line staff

% Neither / nor Net % Don't know agree

49

Increasing the amount of time spent by senior managers with front-line staff in their ward/department

32

45

31

9 *243

+79

13 215 4

+72

Freeing up more time for staff to talk to patients

39

39

9 216 6

+75

Making quality of care a more important component of staff training

39

39

11 215 4

+76

Spending more time talking patients through what to expect and answering any questions

38

40

8 21 8 2

+76

Collecting more feedback from staff and acting on any comments promptly

37

43

8 115 5

+78

Collecting more feedback from patients as they finish treatment and acting on any comments promptly

32

43

12 21 8 3

+72

Setting more meaningful quality targets and providing more feedback on performance Improving initiatives to reduce infection and improve patient safety, such as clearer signs about hand washing

32

37

16 316 4

+64

Giving patients a clearer welcome pack so they know what to expect

31

33

19 515 5

+58

29

39

14 41 9 3

+63

Improving visibility of cleaning schedules so patients/visitors see when areas were last cleaned

27

Having a more clearly defined quality leader in each ward or team

26

Providing staff with more customer service training

20

32

22

38 33

7 26 4

+50

17 61 8 3

+56

27

8 36 4

+42

Base: All staff members (1,030); fieldwork dates: 24th April - 8th June 2009

Improving communication between managers and front line staff is particularly important for staff who hold more negative views around quality. Those staff who are dissatisfied with the

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quality of care at their Trust, or are more likely to criticise their Trust or are not convinced that their Trust places quality of care as its top priority are more likely to be reassured by increasing the communication between managers and front line staff. The same groups of people are also more likely to be reassured that quality of care is a top priority if the amount of time spent by senior managers with front line staff in their ward or department increases. This would suggest that a good relationship and communication between management and other staff, along with greater visibility of mangers on the front-line is extremely important in improving the morale of the most pessimistic staff. Staff felt that improvements were needed around the ways in which feedback is collected from staff and patients and acting upon this. The findings from the discussion groups showed that staff did not always feel comfortable to feedback on errors or share ideas for improvement – a couple thought the process for reporting errors was bureaucratic, while others less senior felt they could be labelled trouble-makers for making suggestions, unless they had sympathetic line managers open to feedback. We get labelled as troublemakers, something like that. So we just grin and bear it, just do our job what the best we can. Staff member

Reality is that these systems are cumbersome, they’re full of individuals who have no particular ability to analyse the realities of what happened and at the end of the day they’re used mostly to try and persuade the relevant legal examination that all due process has been followed to analyse the unfortunate incident and correct. Staff member

This desire by staff to give and receive feedback in order to improve quality of care also comes through strongly in the quantitative research carried out amongst NHS staff. When asked which two or three things they could do tomorrow to improve the quality of patient care, the top three mentions were sharing ideas with colleagues about ways to improve the quality of care (43%), making suggestions to management about how the service can be improved (35%) and having conversations with patients about the quality of care they receive (30%). These are all clear ways in which staff can offer or obtain feedback on their performance. Looking for ways to spend a greater amount of time working with patients was

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mentioned but less often (24%) and improving reporting of incidents or near misses was the least popular of all the options given (12%). 5.2.2.2 Practical steps for staff As part of the quantitative survey, members of staff were asked to identify practical steps that they might be able to take to improve patient care. A lot of the positive measures staff selected most frequently are around sharing ideas and making suggestions.

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Practical steps to improve quality of care: staff perceptions Q

Having thought about quality of care, weâ€&#x;re interested to know whether you think there are things you could do tomorrow to improve the quality of care patients receive?

% mentions Share ideas with colleagues about ways to improve the quality of care

43%

Make suggestions to management about how the service can be improved

35%

Have conversations with patients about how they feel about the quality of care they receive

30%

Learn from other people about how they provide similar services

27% 25%

Keep myself better informed about best practice Look for ways to spend a greater amount of my working time with patients

24%

Involve patients more in decisions about their care

18% 14%

Enrol on training Improve reporting of incidents or near misses

12% 6%

Other None of these

5%

Donâ€&#x;t know

5% 3%

Not stated

Base: All staff members (1,030); fieldwork dates: 24th April to 8th June 2009

Perhaps unsurprisingly, and linked to earlier findings about senior management, staff who do not think that quality of care is a top priority for their Trust, those who are dissatisfied with the

97


quality of care delivered at their Trust and those who would criticise their Trust are more likely than others to think that making suggestions to management about how to improve the service would improve the quality of care. Again, this emphasises the importance of communication issues for those who hold negative views.

98


6. Accountability

99


6. Accountability The research suggests that many people have difficulty judging the quality of their clinical treatment. However, the evidence suggests that people attach importance to the ways in which hospitals make themselves accountable to patients. This research demonstrates that improving aspects of accountability or informing patients about them helps to reassure people that quality is a priority. This chapter discusses the public, patient and staff views of accountability.

Summary Accountability emerges from the research as a key area for patients, the public and staff. There is a feeling that patients should be able to get redress when they are not satisfied, and to hold hospitals accountable. However, many residents - including patients - are not aware of the systems and procedures the hospital has in place to follow-up when things donâ€&#x;t go as planned. Awareness of complaints procedures is also low, although 48% of inpatients agree their local hospital provides them with a clear complaints procedure. Staff say that there is room for improvement in the systems and procedures the hospital has in place to follow-up when things donâ€&#x;t go as planned with 29% saying this needs a lot or a fair amount of improvement. However, they are more positive about the clear complaints procedure (12%). When quality standards fall short of what they expect, the majority of residents agree that an apology would improve their perceptions. Having said this, a significant minority would not tell staff if their expectations were not met because they think it could affect the care they receive.

6.1 Awareness of systems and procedures to ensure safe care Participants in the patient and public discussion groups felt that if a hospital is found to fall short of defined quality standards there should be an appropriate system of support to ensure that issues are being dealt with in a timely and efficient manner. There was a general consensus that the hospital should be held to account but many felt that fines were not appropriate (as the money could be spent on making improvements). Patients were also keen to get redress where they were dissatisfied, with an explanation and a plan for future improvements to avoid similar mistakes.

100


Well, I’d want to go and sit with the person who’s responsible for putting somebody in there with that level of competency. You can’t really blame that individual, well you can and can’t, you’d have to have an investigation and an answer as to why, but then it’s the person above them. You’d want to know, well why has that person been put in there if they’re making mistakes? Male, 18-34, Patient

It needs somebody to go and say look, these are the things that are wrong and these are the things that you need to do about it. So come up with a plan, because we want to see what the plan is going to be, and then we’re going to come back and see how much has changed. Female, 55+, Patient

I don’t think in this situation a fine, something like a fine, a financial solution is at all a sensible idea, is it? Crikey, the National Health Service is struggling enough for money, if you’re going to be, you haven’t spoken to your patients nicely so we’re going to take money off you, that’s ridiculous. Female, 55+, Patient

The quantitative findings show that 41% of the public are satisfied with the systems and procedures hospitals have in place to follow-up when things do not go as planned, 16% are dissatisfied and a further 31% say they do not know. This suggests that hospitals could still do more to better inform people of the systems and procedures they already have in place, as a way of reassuring people of accountability.

101


Ensuring safe care: patient and public perceptions Q

And from what you know or have heard, how satisfied or dissatisfied are you with each of the following aspects of your local NHS hospital? The systems and procedures the hospital has in place to follow-up when things don’t go as planned. Very satisfied

13% Don‟t know

31%

41% Satisfied

28% Fairly satisfied 16% Dissatisfied

Very dissatisfied

7% 9%

12%

Fairly dissatisfied Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Neither satisfied nor dissatisfied Net satisfied: +25

Encouragingly, inpatients are more likely to be satisfied with the systems and procedures to ensure safe care than average (46% versus 41% overall). However, a significant proportion of inpatients state that they do not know about these procedures and systems (27%). Less positively, those with caring responsibilities are more dissatisfied with this aspect (21%, compared to 16% overall). NHS staff seem to be less satisfied than patients and the general public with the systems and procedures that are in place when things don‟t go as planned, with approaching seven in ten stating that improvement is needed in this area (68%). Only one in ten say that no improvement is needed (10%). Staff are more likely to have an opinion on this matter than patients and the public, as just 17% say they don‟t know if the systems and procedures are in need of improvement (compared with 31% of patients and public who say they don‟t know). While this still represents nearly one in five staff, this may reflect disparate staff roles within an NHS Trust. Administrative and estates staff are particularly likely not to know in comparison with other occupational groups (35% compared with 17% overall).

102


Room for improvement - systems and processes when things go wrong: staff perceptions Q

Still thinking about quality of care in your trust, to what extent, if at all, are the systems and procedures in place to follow-up when things don‟t go as planned in need of improvement? No need for improvement

Not stated Don‟t know

17%

29% Improvement needed

A lot of improvement needed

4% 10% 49% No or little improvement needed

7% 39%

A fair amount of improvement needed

A little improvement needed

22% Net improvement needed: +20

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

6.2 Apologising for lower than expected quality of care At a micro level, patients and the public in the qualitative groups accepted that mistakes did happen and felt that in these cases a simple explanation and apology could go a long way. You want an apology. That should go without saying that it’s their fault and they know it’s their fault. And there should be an explanation as to why it happened, and they should show you why it shouldn’t, wouldn’t happen again, what procedures they’ve now put in place. Female, 18-34, Patient

This also comes out through the qualitative research, with four in five agreeing that an apology would count towards their overall experience, even if mistakes have been made along the way (82%). Just one in eight disagree with this (12%).

103


Apologising for bad experiences: patient and public perceptions Q

Please could you tell me the extent to which you agree or disagree with the following statement with regards to your local NHS hospital?

If a visit to hospital fell short of what I would expect, an apology would still count towards my experience overall. No opinion Strongly disagree 12% Disagree Tend to disagree 4%3% Neither agree nor disagree

7% 4%

36% Strongly agree 82% Agree

Tend to agree

46%

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Net agree: +70

6.3 Providing a clear complaints procedure As stated in the previous section of this chapter, having the opportunity to feed back about quality of care is something to which people – visitors and inpatients in particular – attach high importance (although, as the literature review notes, being told how to make a complaint about care received is relatively less important than other aspects of care among patients). When considering whether their local hospital provides a clear complaints procedure, 43% of residents agree and just 12% disagree. However, there is a substantial minority that has no opinion (35%) and therefore may be uninformed on the matter. The findings show some similarities to the CQC inpatient survey results. In 2008, just 38% of respondents said that they had seen a poster or leaflet explaining how to complain about the care they had received15.

15

ttp://www.cqc.org.uk/usingcareservices/healthcare/patientsurveys/hospitalcare/inpatientservices.cfm

104


Providing a clear complaints procedure: patient and public perceptions Q

From what you know or have heard, to what extent do you agree or disagree with the following statement? Your local hospital provides a clear complaints procedure. Strongly agree

21% No opinion

35%

43% Agree

22% Tend to agree

6% 12% Disagree

Strongly disagree

7%

9%

Tend to disagree

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

Neither agree nor disagree

Net agree: +31

Inpatients are more likely than average to agree that their hospital has a clear complaints procedure (48% versus 43%). NHS staff do not seem very satisfied with the current procedures for patients to make complaints, with close to half (44%) thinking that some form of improvement is needed and one in three thinking that no improvement is needed (36%). Only two per cent think that a lot of improvement is needed however.

105


Complaints procedure: staff perceptions Q

Still thinking about quality of care in your trust, to what extent, if at all, is the procedure for patients to make complaints in need of improvement? Not stated Don‟t know

17%

12% Improvement needed

A lot of improvement needed A fair amount of improvement needed

3% 36%

2%

No need for improvement

68% No or little improvement needed

10%

32%

A little improvement needed

Net improvement needed: +56

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

6.4 Feeding back about poor quality of care Some participants in the general public groups suggested that there should be an easier and anonymous way to feed back or complain when the quality of care did not match their expectations and appeared to be unaware of the complaints procedures their local hospital may already have in place. They felt that currently many patients do not complain for fear of being ignored or of facing inferior treatment in the future. Staff also felt that it was important for them to be able to report issues without fear of retribution. I think a lot of complaints are not made in hospitals, the people lying in beds are afraid to complain because if they complain to the nursing staff they think to themselves, oh I’m going to get ignored Male, 55+, General Public They won’t respond.

It’s like we have this magazine that

people write into and if someone puts anonymous they say they can’t do anything unless they put their name down. Staff member

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Given this perceived lack of accountability discussed by the qualitative patient and public participants, a potential barrier to high quality of care is patients or visitors not feeling able to feed back to staff when care does not meet their standards. Over a third of respondents in the survey agreed that they would not feed back on poor quality of care to staff because of how this would affect their next visit (38%).

Feeding back quality of care: patient and public perceptions Q

Please could you tell me the extent to which you agree or disagree with the following statement with regards to your local NHS hospital? Even if the quality of care does not reach what I would expect, I wouldn’t tell staff because I think it would affect how they treat me on my next visit. No opinion

2% Strongly disagree 57% Disagree

Strongly agree

17% 37% Agree

32% 21% Tend to agree

Tend to disagree

4% 25%

Base: All respondents (3,515) ; fieldwork dates 10th March – 14th April 2009

Neither agree nor disagree

Net agree: -20

Worryingly, inpatients are more likely to strongly agree that they wouldn‟t tell staff about their concerns in case it affected them on their next visit (20% compared to 17% overall). Agreement that they would not feed back on poor quality of care tends to be highest among ethnic minority residents – over half (51%) agree, while just 44% disagree (compared to 38% and 57% overall respectively). Those from less affluent backgrounds are more likely to agree (42% of C2DEs versus 33% of ABC1s), while women are more likely to be reluctant about feeding back than men (41% versus 33%). The next chapter focuses on information provision in terms of quality.

107


108


7. Information provision

109


7. Information provision Having now looked at various aspects of quality, this chapter explores what information patients, the public and staff have accessed, and what they would like to be able to access, about quality.

Summary Patients and the public in the discussion groups tended to get information about their local hospital and its priorities from local media (e.g. local newspapers or regional television news) and via word of mouth in the local community. Although patients tended to be positive about the overall quality of care they had received from their hospital, their perceptions of the hospital as a whole were often still affected by negative press and word of mouth. Almost without exception in the groups, the information participants had heard tended to be negative, and this is corroborated by the survey, where approaching half say the things they hear about their local hospital from other people and through the media are generally negative. Despite this, the majority of those who say the things they hear are generally negative would still choose to go to their local hospital – locality seems more important than these negative reports. In terms of the information they would like to see on quality, information on waits while at the hospital, information on hospital infection rates and information on the systems and procedures in place in the hospital to follow-up when things donâ€&#x;t go as planned are some of the more useful aspects identified. However, in the discussion groups, participants admitted they were unlikely to seek out this information unless they were going to be a patient. Among staff, only more senior and clinical staff said in the groups they regularly accessed information about quality of care. The survey found that almost exactly the same proportions of staff have and have not seen information within the last three months or so on the quality of care provided by their team or ward (44% have and 43% have not). Those who have seen information have seen information mainly about patient experience, staff training and adverse events, and generally found it useful. Significantly, very few staff report seeing information which compares the performance of their ward or team with others outside their hospital (eight per cent), or with other wards and teams within their hospital (14%). This raises questions about how these wards or teams would recognise poor performance, with a view to improving in line with other wards or teams.

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On the whole, in the groups, staff were interested in seeing more information about quality of care, particularly in relation to their own, or their departmentâ€&#x;s performance.

7.1 Sources of information about quality of care 7.1.1 Sources of information for patients and the public Patients and the public in the discussion groups tended to get information about their local hospital and its priorities from local media (e.g. local newspapers or regional television news) and via word of mouth in the local community. Some had friends or relatives who worked in the hospital and often used their reported experiences to support information gained from media coverage. Almost without exception this information tended to be negative, focusing on things that had gone wrong and instances where the local NHS was failing to meet the needs of the local community. For instance, participants in one of the general public groups mentioned that on that day there was a report in a local paper about a patient not being provided with a certain drug that was freely available in other parts of the UK. I think a lot of our attitudes, and attitudes generally, are driven by media reports and media reports tend, almost exclusively, to concentrate on failings or feelings. Male, 18-34, General Public

As previously discussed, patients tended to be positive about the overall quality of care they had received from their hospital but their perceptions of the hospital as a whole were often influenced by negative press and word of mouth. It is important to note that many participants agreed that the media was not a reliable source of information but given that this was their only source of information, they felt it was inevitable that their perceptions would be influenced by it. There’s always some programme content on BBC Midlands today or Central News and a large style segment of the programme of somebody’s problem with the NHS. Male, 18-34, Patient

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It’s on the TV when they close wards because of bugs, dirt. Male, 55+, Patient

I think now and again, in the doom and gloom papers, like the Daily Mail, which I rarely do buy, now and again they’ll produce a league table saying the average waiting list in Europe, and we’re probably somewhere down the bottom, just above Albania or somewhere like that. Male, 18-34, General Public

A couple of patients had tried to access information about their local hospital online (prior to their hospital visit). However these participants were in the minority and overall awareness of the types of information available was extremely low in all of the groups. There are various reports on the hospitals, but the average person doesn’t know anything about them, they’d probably go to the GP and if you need treatment he will say to you, well you can go here or you can go there and da, da, da, this hospital has got a good, good results for that actual surgery that you need or whatever, but normally you wouldn’t know about it. Female, 18-34, General Public

We don’t know what goes on inside the hospital until we’re in there ourselves and see it with our own eyes. Male, 18-34, General Public

The quantitative research heavily reflects the qualitative findings. Approaching half of residents say the things they hear from other people and from the media about their local hospitals are generally negative (49%), while a further 16% tend to hear mixed coverage. Only three in ten (30%) generally hear positive things.

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Media coverage: patient and public perceptions Q

Would you say that the things you hear from other people and from newspapers, television, the radio and the internet are generally positive or negative about your local hospitals? Donâ€&#x;t know

5% 30%

Generally negative

Generally positive

49% 16% Mixed

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

As the chart below demonstrates, three in four would still choose to use their local hospital even after hearing mixed or negative stories (74%). From other research, it seems that the culture of choice and awareness of the right to choose to go to a different hospital (i.e. not the local hospital) are still bedding in. It seems then, that despite negative media stories, other factors such as locality have a large impact on choice. However, negative stories from the media and from friends and family may still have a substantial impact on the perceptions of those who continue to use their local hospital. One in five say they would not choose to go to their local hospital given the mixed or negative information they have heard about it (22%).

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Media influence: patient and public perceptions Q

You may be aware that, for most conditions, patients referred to hospital are able to choose to go to any hospital. Bearing in mind what you have heard or read about your local hospital, do you think you would still choose to go your there, or not? Don‟t know

4% No

22%

74% Yes Base: All who say the things they hear are mixed or generally negative (2,278); fieldwork dates 10th March – 14th April 2009

7.1.2 Sources of information for staff The information channels staff said they used in the qualitative work tended to be more varied than those accessed by patients and the public. Only senior staff said they regularly accessed information about quality of care (such as infection rates, patient feedback and average waiting times). A few felt that their line managers kept them well informed and had regular team briefings in which all relevant information was relayed. Others tended to rely on ad hoc sources of information, such as the staff magazine, word or mouth and local media. They felt that it was not their job to review and monitor quality so were less likely to search information about this. It’s just what you pick up reading, and they have a newsletter, so sometimes there’s bits and pieces in there that you might read. So you pick up the cleaners have won awards for doing, updating their cleaning skills or whatever it, you know. So you pick up that type of information from a newsletter. Staff member

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Well that’s what the seniors do, they go round inspecting don’t they that’s what your supervisors are. Staff member

Access to information about quality was thought to be fairly limited. While most staff assumed this information was available to them on their staff intranet they felt that they rarely had the time to “boot up” the computer to search for this, and hard copies would be more accessible. All our policies are on the internet but it’s having the time to sit down and access them all. It’s much easier if you’ve got, I know it’s more paperwork and we don’t want that, but if you’ve got them available to drag one out rather than going, getting logged on to the computer. Staff member

The results from the quantitative staff survey confirm this, suggesting that information about the quality of care being provided locally is not reaching all NHS staff. Almost exactly the same proportions of staff have and have not seen information within the last three months or so on the quality of care provided by their team or ward (44% have and 43% have not).

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Information seen about quality of care: staff Q

In the last three months or so, have you seen any information about the quality of care provided by your team or ward? Not stated Donâ€&#x;t know

12%

2%

44%

No

Yes

43%

Base: All staff members (1,030); fieldwork dates 24th April - 8th June 2009

Although the quality of care information is not reaching all staff, it may be having an impact on those it does. Staff who are more likely to agree that quality of care is a top priority for their Trust, those who think that it has become more of a priority over the last two years and those who are satisfied with the quality of care delivered by their Trust are all more likely than others to have seen information on quality of care (50%, 54% and 53% respectively compared with 44% overall). Managers, and nurses and midwives are most likely to say they have seen information on quality of care (65% and 56% respectively). Perhaps surprisingly, half of doctors and consultants say they have not (52%), broadly in line with the average. When those who have seen information were asked what the information was about, information about patient experience was most commonly mentioned (by 54%). Staff training and adverse events (e.g. infections) had the second and third highest number of mentions (44% and 43% respectively).

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Focus of quality of care information (1): staff Q

What was this information about? % Agree 54%

Patient experience Staff training

44%

Adverse events (e.g. infections)

43%

Clinical outcomes

37%

Activity levels

36%

Efficiency

34%

Other Don‟t know/can‟t remember Not stated

6% * 3%

Base: All staff members who have seen information about the quality of care provided by their ward or team (449); fieldwork dates 24th April - 8th June 2009

Most commonly, the information staff had seen compared their team or ward‟s performance with that of other wards or teams in the hospital (32%). Very few staff have seen any information which compares their performance with others outside the hospital (19%). The same proportion say that the information did not compare their team or ward‟s performance with any other hospital or team (32%). If we look at the results overall, it demonstrates that relatively few staff have access to information which compares their performance with other teams and hospitals.

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Comparisons in quality of care information: staff Did this information compare your ward or team‟s performance with…?

Q

% Agree Other wards or teams in your hospital / trust

32%

Other hospitals / clinics outside your trust

19%

Other hospitals / clinics in your trust

10%

None of these

32%

Don‟t know/can‟t remember Not stated

13% 6%

Base: All staff members who have seen information about the quality of care provided by their ward or team (449); fieldwork dates 24th April - 8th June 2009

The chart above includes those who have seen information about the quality of care provided by their ward or team. Interestingly, if we look at all staff included in the survey, very few report seeing information which compares the performance of their ward or team with others outside their hospital (eight per cent), or with other wards and teams within their hospital (14%). This raises questions about how these wards or teams would recognise if they were performing relatively poorly, and how they would be able to improve performance in line with others'. The information seen by staff about quality of care is largely considered useful. Approaching four in five of those who have seen information about the quality of care provided by their ward or team found it useful (78%), and one in three found it very useful (34%).

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Usefulness of information: staff perceptions Q

And how useful, if at all, was this information to you? Don‟t know Not at all useful

14% Not useful

Not very useful

Not stated

4%4% 3%

Very useful

34%

12%

78% Useful

44%

Fairly useful Net useful: +64

Base: All staff members who have seen information about the quality of care provided by their ward or team (449); fieldwork dates 24th April - 8th June 2009

7.2 Information requirements of patients and the public In general, patients and public in the qualitative research wanted to see more information about their local hospital, its priorities and its performance. They stressed that as a public body the NHS should be held accountable for the decisions it makes. Well, you’ve got to let the public know in some way or other what you are achieving. Male, 18-34, General Public

The NHS is a public service, it’s nationalised, it’s run by the people and paid for by us so, therefore, we should be able to get notes or something from the people who make decisions and say, this is what we’ve decided and then we hold them accountable for that. Male, 18-34, Patient

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However, when asked whether they would like to receive information specifically in relation to quality, there was a less clear-cut message. In fact, when shown the patient scenarios taken from the NHS Choices website, patients had very mixed opinions about the potential use of these. While some found it helpful to relate these reported experiences to their own, others were sceptical about the use of such feedback given that it was from only a small selection of individuals, who were likely to have very unique experiences. Moreover, patients felt that they didn‟t have any option but to go to their local hospital for treatment and consequently they only wanted to hear that their hospital was providing good quality care (and feel confident that this was true). This isn’t systematic, this is anybody who thinks they’ll put something up, so you’re only getting the opinions of anybody who can be bothered to give them. Female, 18-34, Patient

People like to moan though, don’t they, people like to write about negativities? So that’s the most, you wouldn’t sit there and say, yeah I had a brilliant time in the NHS. You’re going to go on a website and say, they did this wrong, they did that wrong. Male, 18-34, Patient

If I was going to buy a car, then I’d look at the review on the internet, Top Gear and all that, and it’d say good things and bad things about this car, and it’d probably sway me not to pick it. But going on the NHS and reading good things and bad things about the NHS aren’t going to sway me, because I’m forced to use it. So why even go down this route? Male, 18-34, Patient

Nevertheless, it was generally felt that quality of care should be measured and that hospitals should be held accountable if they fell short of set standards. Some participants wanted to see hospital league tables so that they could gauge how well (or not) their local hospital was performing nationally. Others were strongly opposed to this idea, saying that league tables would be of little use to them (for the same reasons they disliked the patient scenarios).

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Regardless of their stance on league tables, there was an overall consensus that a hospital‟s performance should be monitored by an independent body, whose role was to provide unbiased and reliable information to the public16. An independent enquiry, those people I would trust, yes, because they’ve got the figures and they’re not going to manipulate them to suit anybody because, well it’s in the public interest and they don’t dare, or if they did there’d be a stink. Male, 35-54, General Public

I’m in favour of having an independent body of people who can assess how well a hospital is performing. Male, 18-34, General Public

Despite calling for such data to be made available, as we may expect participants in the general public groups admitted that they would only actively seek this information if they were likely to be a patient at their local hospital. One general public group also suggested the provision of hospital bulletins (containing information about the quality of patient care, the processes in place to ensure it was of an excellent standard and how this was being measured) for local residents but, again, felt that they would only read these if they or one of their relatives was a patient. Nevertheless, they felt that if their local hospital provided these updates to all current patients it would help to make them feel valued and that quality of care was being taken seriously. Looking at the results of the quantitative research, the majority of people are enthusiastic about all of the suggestions made for information provision. When concentrating solely on the information that people would find very useful, the top three mentions are information on waiting times while at the hospital (70%), information on infection rates (63%) and information on systems and procedures (52%). As reflected in the qualitative groups, people are relatively less interested in information from other patients, such as satisfaction scores (32% would find this very useful), information about outcomes (30%) and patient reviews (26%).

16

There appears to be little awareness of the Healthcare Commission, or the Care Quality Commission and their role in monitoring the NHS.

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Information on quality of care: patient and public perceptions Q

How useful, if at all, would each of the following be for you when visiting your local NHS hospital? % Very useful % Fairly useful

% Not very useful % Not useful at all

Information on how long you will have to wait while at the hospital

70 63

Information on hospital infection rates (e.g. MRSA) Information on the systems and procedures the hospital has in place to follow-up when things don‟t go as planned Clinical results for the hospital Information on cleaning schedules, showing when an area has last been cleaned Information on how to feed back about services, whether positive or negative Information on the role of different hospital staff Patient satisfaction scores (e.g. from a survey of patients) Information from other patients on how much the care they received has helped to improve their condition Reviews by previous patients

52 48 43 41 33 32 30 26

Net useful

% Don't know

26

21 27 7 2 1 38 5 22 38 9 32 36 15 51 48 7 2 1 48 14 42 47 15 5 2 52 46 17 46 19 62

+92 +81 +84 +74 +59 +80 +64 +59 +53 +48

Base: All respondents (3,515); fieldwork dates 10th March – 14th April 2009

7.3 Information requirements of staff On the whole, all staff were interested in seeing more information about quality of care, particularly in relation to their own, or their department‟s performance. They wanted to know what they were doing well and where they needed to improve and felt that this information would help them to provide excellent quality of care. Receiving this feedback would also increase their job satisfaction, as they would have evidence of the care they were providing. Well first of all I’d like to have feedback on how I’m doing because, and I think all my colleagues would because contrary to the way it’s painted I think most surgeons are really desperate to provide the best possible service. Staff member

One thing that is difficult to do but one field that would be nice to do is do more on focus groups rather than just patient satisfaction surveys, but it’s notoriously difficult to get patients in. Staff member

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Some staff said that patient feedback was already collected (as part of an exit survey) but they were unclear about what the eventual use of this information. It appeared that they did not receive a copy of the results. When people are discharged we go through the checklist and on that checklist it does say, were you happy with the information you’ve been given? Are you happy? I think there’s a bit in there which says, were you happy with your care? There’s certainly a bit that says, are you happy to be discharged and have all your questions been answered? Staff member

In general, staff felt that they were unlikely to access information about quality of care unless it was directly relevant to their role. They were also sceptical about the potential use of an online information source and would prefer to access hard-copy information that was readily available on their own ward. You could have information available in the ward office. Maybe, I don't know, a notice up maybe, per centages or ticks on certain areas and good, bad… Staff member

Some more senior staff felt that guidance on what to measure and how to measure it would be very useful. Advice regarding what to measure and how to measure it would be really helpful. Staff member

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124


Appendices

125


1. Statistical reliability Because a sample, rather than the entire population, was interviewed the percentage results are subject to sampling tolerances – which vary with the size of the sample and the per centage figure concerned. For example, for a question where 50% of the people in a (weighted) sample of 3,515 with an effective sample size of 3,332 respond with a particular answer, the chances are 95 in 100 that this result would not vary more than two per centage points, plus or minus, from the result that would have been obtained from a census of the entire population (using the same procedures). An indication of approximate sampling tolerances for both surveys (patient/public and staff) are given in the table below. Size of sample on which the survey results are based

Approximate sampling tolerances applicable to per centages at or near these levels 10% or 30% or 50% 90% 70% ± ± ± 3,515 interviews (effective base 3,332) 1 2 2 1,030 interviews (unweighted) 2 3 3

For example, with a sample of 1,030 where 30% give a particular answer, the chances are 19 in 20 that the “true” value (which would have been obtained if the whole population had been interviewed) will fall within the range of plus or minus three per centage points from the sample result. Strictly speaking, the tolerances shown here apply only to random samples with no design effects; in practice good quality quota sampling has been found to behave in the same way. When results are compared between separate groups within a sample, different results may be obtained. The difference may be “real”, or it may occur by chance (because not everyone in the population has been interviewed). To test if the difference is a real one – i.e. if it is “statistically significant”, we again have to know the size of the samples, the percentage giving a certain answer and the degree of confidence chosen. If we assume the “95% confidence interval”, the differences between the two sample results must be greater than the values given in the table overleaf:

126


Size of samples compared

Differences required for significance at or near these per centage levels 10% or 30% or 50% 90% 70% + + + 3 5 6 6 9 10 3 5 6

692 (inpatients) vs. 601 (visitors) 200 and 200 (e.g. between PCTs) 2,966 (white residents) vs. 359 (ethnic minority) 115 (staff working less than 2 years) vs. 561 (staffworking more than 10 years)

6

127

9

10


2. Definition of social grades The grades detailed below are the social class definitions as used by the Institute of Practitioners in Advertising, and are commonly used on quota surveys carried out by Ipsos MORI (Market & Opinion Research International Limited). Social Grades Social Class

Occupation of Chief Income Earner

Per centage of Population

A

Upper Middle Class

Higher managerial, administrative or professional

B

Middle Class

Intermediate managerial, administrative or professional

C1

Lower Middle Class

Supervisor or clerical and junior managerial, administrative or professional

C2

Skilled Working Class

Skilled manual workers

D

Working Class

Semi and unskilled manual workers

16.9

E

Those at the lowest levels of subsistence

State pensioners, etc, with no other earnings

11.7

128

2.9

18.9

27.0

22.6


3. Logistic regression This appendix outlines how the key drivers analysis was carried out for chapter five of this report. Multivariate techniques allow one to assess which of a selection of relevant independent variables are statistically related to a given dependent variable when all other variables under consideration have been taken into account. Multivariate techniques allow us to explore the associations between variables. However, evidence of an association does not necessarily imply a causal relationship. The results presented here therefore identify factors associated with high odds of agreeing that their Trust places high quality care as its top priority. The results should not be interpreted as indicating a causal link. In this report, Binary Logistic regression has been used, as the dependent variable is binary (Agree vs. Neither/nor/Disagree). Responses to Q1 (“To what extent do you agree or disagree with the following statement? „My Trust places high quality care as its top priority‟?” for staff and “To what do you agree or disagree that your local NHS hospital puts high quality of care as its top priority?” for patients/public) were coded into two categories: Agree vs. Neither/nor/Disagree. The following independent variables were considered as possible drivers. These variables were selected as being those which might theoretically be considered as associated with perceptions of quality of care:

3.1 Patients, visitors and the public Q5. From your own experience, to what extent are you satisfied or dissatisfied with [individual services]…? Q7. From what you have heard or what you know, how satisfied or dissatisfied are you overall with the quality of care patients receive at your local NHS hospital? Q10. From what you know or have heard, to what extent do you agree or disagree with the following statement...[measuring various aspects of quality]? Q11. And from what you know or have heard, how satisfied or dissatisfied are you with each of the following aspects of your local NHS hospital...[measuring various aspects of quality]? Q12. To what extent do you agree or disagree that the following people at your local NHS hospital have high quality of care as their top priority?

129


Q14. What, if anything, do you think makes it difficult for hospitals to deliver high quality of care? Q16. You may be aware that, for most conditions, patients referred to hospital are able to choose to go to any hospital. Bearing in mind what you have heard or read about your local hospital, do you think you would still choose to go your there, or not? Q17. I am going to read out a number of statements. For each of the statements, please could you tell me the extent to which you agree or disagree with regards to your local NHS hospital? Demographics: gender, age, ethnicity, working status, social class, parental status, long-term condition, caring responsibilities, work in NHS, language, Mosaic and IMD. We ran three different models for this group – one for the general public, one for patients and one for those who have visited someone in hospital.

3.2 Staff Q2. How satisfied or dissatisfied are you with the overall quality of care patients receive in your Trust? Q4 (treated as categorical). In the last three months or so, have you seen any information about the quality of care provided by your team or ward? Q8. Thinking about quality of care in your Trust, please indicate whether each of the following areas is in need of no improvement, in need of a little improvement, in need of a fair amount of improvement or in need of a lot of improvement? Q12. To what extent do you agree or disagree with each of the following statements about the general and clinical management at your Trust? Demographics: gender, age, ethnicity, length of service in the NHS, occupational group.

3.3 Interpretation of Model The results presented in this report only include those variables which are statistically related to the outcome variable after the other factors have been controlled for. The tables present the odds ratios (Exp (B)), along with their confidence levels. The table below is an example from the general public regression.

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General public Key driver

Odds ratio

Confidence Interval (95%) Lower

Upper

Q7. Level of satisfaction with overall quality of care provided by local NHS hospital

2.09

1.63

2.69

Q10. Level of agreement your local NHS hospital provides safe medical care for patients

1.79

1.42

2.25

Q11. Level of satisfaction with aftercare patients receive once they have finished their treatment

1.42

1.11

1.82

Q12. Level of agreement that senior management have high quality of care as their top priority

1.31

1.08

1.60

Personally work in the NHS

4.79

1.50

15.27

No children under 16 in the household

0.55

0.34

0.89

Q11. Level of satisfaction with communication between hospitals and GPs

1.29

1.03

1.60

Q11. Level of satisfaction with friendliness of staff

1.33

1.01

1.75

General public Nagelkerke R Square = 46% Source: Ipsos MORI

Odds Ratio is interpreted as the change in the odds of a person agreeing to the outcome given a change in the characteristic of that respondent. The easiest way to interpret the odds ratio is to think of two respondents who are identical except in respect of the factor under consideration. For example in the model above we can interpret the odds ratio for agreeing quality is their local hospitalâ€&#x;s top priority in the following way. Consider two people who have given exactly the same answers to the other questions in the model, but one of them (person A) is very satisfied with the overall quality of care patients receive from the hospital, while the other (person B) is only fairly satisfied. We can say therefore that person A is, on average, likely to be two times (exp(B) = 2.09) more likely to agree that their hospital places high quality care as its top priority than person B. Please note an odds ratio greater than 1 implies an increase in the likelihood of agreeing, whilst an odds ratio less than 1 indicates a decrease in the likelihood of agreeing.

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3.4 Technical details 3.4.1 Model selection In the model, variables enter or are dropped based on the Likelihood Ratio test as the Forward LR selection process was selected. This process is not dissimilar to the stepwise selection process used in Ordinary Least Squares regression. Forward LR picks the “best� variable (the one that explains the most variation in terms of the reduction in the -2LL Chisquare statistic) to enter the model, then all variables in the model after that inclusion are examined for possible removal and this is repeated until no more can be removed. If the one just added is the only one removed, it stops. If not, it goes to another round of entry and possible removal, until nothing meets entry or removal criteria or the model is duplicated.

3.4.2 Significance Variables are added or removed based on the omnibus test using the -2LL Chi-square statistic. It is possible for some factors to be significant but for their direction of strength expressed by the EXP (B) value to be inconsistent with their respective crosstabulation17. In these situations we have removed the variable from the stepwise model selection process and rerun the regression. Further details on binary logistic regression can be found in Dobson (1990)18, Demaris (1992)19 and Menard (2002)20.

17

This could be due to confounding effects with other variables in the model. Dobson, A. (1990) An Introduction to Generalised Linear Models. London: Chapman and Hall. 19 Demaris, A. (1992) Logit Modelling: practical applications. Sage University Series on Quantitative Applications in Social Science. Newbury Park, California: Sage Publications. 20 Menard, S. (2002) Applied Logistic Regression Analysis. Revised Edition. Sage Series on Quantitative Applications in the Social Sciences Newbury Park , CA : Sage. 18

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4. Public perceptions around cleanliness in hospitals This study was conducted by the Ipsos MORI Social Research Institute on behalf of NHS West Midlands, the organisation responsible for healthcare services in the West Midlands region. It was conducted in response to findings which show that the public view improving cleanliness in hospitals as a key priority for the NHS. Furthermore, following the launch of national government and local initiatives to ensure hospitals are clean and safe environments, such as the deep clean of hospitals announced by Health Secretary Alan Johnson in November 2008, issues surrounding hospital cleanliness have been reemphasized as of prime importance. Findings from the annual 2008 telephone survey of West Midlands residents revealed that over half of residents (54%) felt hospital cleanliness needed either a fair amount or a great deal of improvement. Residents‟ top priority was felt to be cleanliness, as it was cited by 18% as the most important thing to improve.21 It has also been found from previous work in the NHS that a negative experience in terms of cleanliness can override any positive messages the NHS communicates about its work to improve cleanliness and reduce infection levels. The SHA commissioned Ipsos MORI to conduct research with members of the general public to explore the perceptions underlying these results. The findings from the research are intended to feed into an action plan that will focus on what information is needed to inform and educate the public about improved cleanliness and reduced infection levels, along with actions, which would reassure the public that cleanliness is a priority.

4.1 Aims and objectives The overall aim of the study was to explore what drives perceptions of cleanliness and what would increase public confidence in the cleanliness of their hospitals, with a view to developing recommendations around effective communication and education strategies. In particular, this study focused on answering several key questions: 

How clean do people feel local hospitals and healthcare services are?

What is understood by healthcare associated infections, and infection rates?

21

NHS West Midlands Annual Telephone Survey, 2008, Ipsos MORI Social Research Institute.

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What drives these perceptions, is it the media or people‟s own experiences?

What, if at all, is the interplay between fears of infection and concerns about cleanliness?

What does “clean” mean to people and what actions or environments reassure them?

What measures and information have residents noticed in hospital or heard about from the NHS? What was the impact of that? And lastly

What are some potential ways of addressing concerns about cleanliness? And consequently what would people like to know about cleanliness and infection rates, and the best ways of telling them about it?

4.2 Methodology A total of eleven qualitative discussion groups (9 full discussion groups and 2 mini groups) with a range of residents across the West Midlands were carried out between 19 th January and 2nd February, 2009. A discussion guide was used to direct the discussions. This was produced in consultation with NHS West Midlands and is appended to this report. Verbatim comments are used throughout the report. These are attributed by respondent characteristics and location. The discussion groups were composed of a range of West Midlands residents who fit a number of specified criteria. Quotas were set on age, gender, ethnicity, and social grade in order to obtain a well rounded sample of respondents. Furthermore, criteria such as „recent or no hospital experience‟ and „views on improvements needed in regards to cleanliness‟ were assessed in order to represent residents with a variety of backgrounds and experiences with healthcare services. For Pakistani and Indian groups, specific criteria such as „English not as a first language‟ were also included. This was to ensure any resulting messages or communication strategies would be able to be targeted to specific groups effectively. A detailed breakdown of each group can be found in the table overleaf.

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Group Breakdown Group

Gender

Age

#

Social Grade

1.

MALE

55+

22

Any

ONLY 2.

FEMALE

Mixed

Urban

Location /

Hospital

Views on

religion

/Rural

Date

Experience

Improvement

Pakistani/

Urban

Birmingham

Patient within

Mixed

28 / 01

last year

Birmingham

Patient within

28 / 01

last year

Muslim 55+

Any

ONLY 3.

Ethnicity/

Pakistani/

Urban

Muslim 35-

ABC1

Mixed

Urban

Birmingham

Non patient

28 / 01

within last 2

54

Mixed

Mixed

years 4.

Mixed

5.

Mixed

55+

16 -

C2DE

ABC1

White

White

Rural

South

Non patient

Staffordshire

within last 2

19 / 01

years

South

Patient within

Staffordshire

last year

Rural

34

Mixed

Mixed

19 / 01 6.

Mixed

7.

Mixed

55+

35 -

ABC1

ABC1

White

White

Rural

Rural

Warwickshire

Patient within

22 / 01

last year

Warwickshire

Non patient

22 / 01

within last 2

54

Mixed

Mixed

years 8.

Mixed

16 -

Any

34

Indian/

Urban

Hindi

Sandwell

Non patient

2 / 02

within last 2

Mixed

years 9.

Mixed

35 -

Any

54

10.

Mixed

35 -

Indian/

Urban

Sandwell

Patient within

2 / 02

last year

South

Patient within

Birmingham

last year

Sikh

C2DE

Mixed

Urban

54

Mixed

Mixed

27 / 01

11.

Mixed

35 -

C2DE

Mixed

Urban

54

22

South

Non patient

Birmingham

within last 2

27 / 01

years

A definition of social grades can be found at appendix A2.

135

Mixed


5. Planned care patient experience This study aimed to further develop the findings of the Planned Care Patient Experience Survey. The postal survey – carried out in November and December 2008 – aimed to feed into the PCT‟s action plans for improving care pathways. The survey revealed that satisfaction with health services (as well as response to the survey) is lower among some audiences including younger people and minority ethnic groups. It is important that the NHS explores these issues further, and therefore this work aimed to: 

explore differences in satisfaction among a range of audiences and locations, to ascertain whether there are differences in patients‟ experiences, or differences in perceptions and expectations;

engage with audiences who are less likely to have responded to the postal survey (such as ethnic minority residents); and

explore the details of specific aspects of the care pathway.

5.1 Methodology In order to meet these objectives, we carried out a programme of 16 discussion groups, with residents in the West Midlands SHA region. Participants for the discussion groups and in-depth interviews were recruited face-to-face by Ipsos MORI recruiters, each group comprising around 10 people. Quotas were set on gender, age, social grade, and ethnicity. The locations and groups of people we opted for were intended to broadly cover different groups across the West Midlands to include as wide a spectrum of residents as possible. Some locations and groups were derived from the planned care survey, looking at areas where there were differences in experiences which needed further investigation. The areas were selected to ensure we included a mix of affluent and deprived areas as well as rural and urban areas. Fieldwork was carried out between 14th May and 30th June 2008 (a break in fieldwork during local elections). Each discussion group lasted approximately 90 minutes, and was led by a moderator who used a discussion guide (please see the appendices).

136


5.2 Audiences and recruitment The following table shows a summary of the discussion group audiences and locations. All discussion groups consisted of a good mix of male and female participants (except where stated) and all participants had been referred from their GP for treatment at a hospital. Italicised locations were groups consisting of patients with long-term health conditions. Additional quotas Location

Age

such as social grade or ethnicity

Stoke

16-34

C2DE

N. Staffordshire (rural)

55+

ABC1

N. Staffordshire (rural)

35-54

C2DE

Coventry

55+

C2DE

Coventry

20-45

Punjabi speakers

Solihull

55+

C2DE

Solihull

35-54

ABC1

S. Birmingham

46+

Female Urdu speakers

S. Birmingham

16-34

ABC1

Herefordshire (rural)

55+

ABC1

Herefordshire (rural)

16-34

Any social grade

Shropshire (rural)

16-34

C2DE

Shropshire (rural)

35-54

ABC1

Heart of Birmingham

46+

Male, Gujarati speakers

Stoke

35-54

South Asian

Heart of Birmingham

16-45

Polish speakers

137


Perceptions of quality in NHS secondary care