Statement of principal findings

The online comments analysed in this study paint a generally positive picture of healthcare services provided by the NHS in England. Our quantitative analysis of the patient comments revealed the most commonly used linguistic markers of positive evaluation occurred approximately three times as often as markers of negative evaluation and, on average, across approximately three times as many comments. Patients’ experiences and impressions of their treatment, communication, staff members’ interpersonal skills and system/organisational issues were identified as key to the ways that healthcare services were both positively and negatively evaluated. Of these key themes, treatment exhibited the highest proportion of positive feedback, occurring alongside the positive evaluation words 87% of the time. Communication was also evaluated positively overall (77%), while interpersonal skills were only evaluated positively 44% of the time and system/organisational issues fared worst of all with only a 41% positive evaluation.

Qualitative examination of the data was able to reveal the more precise nature of the evaluation made in the comments, as well as uncover overlaps and nuances between the key themes of positive and negative feedback. This part of the analysis suggested that as well as constituting a key theme in its own right, staff members’ interpersonal skills also emerged as a frequent driver of both positive and negative feedback in relation to how treatment and staff communication skills were evaluated. Other frequently cited drivers of positive and negative feedback included accessibility to care, patient centredness, and staff-to-staff and staff-to-patient communication. Staff technical competence was a less prominent driver of feedback, cited only in relation to the evaluation of treatment itself, and accounting for a relative minority of these comments. Our findings therefore support the notion that there is a discord between the significance that practitioners and patients place on technical competence when judging the overall quality of care.29

Strengths and weaknesses of the study

This study has examined the largest and most up-to-date collection of patient feedback on NHS services in England in any format. Our use of quantitative computer-assisted linguistic techniques has produced large-scale, generalisable insights into this dataset. Yet at the same time, the more fine-grained, qualitative analysis was able to elucidate areas of difference and overlap that have been overlooked by research employing solely quantitative approaches in the past.

Although this dataset has proven to be a valuable resource for learning about individuals’ perspectives on the healthcare services they access, its lack of metadata regarding the demographic information of individual contributors meant that it was not possible to attribute particular types of comment or concern to any demographic group. It is also worth bearing in mind that the majority of the comments we analysed (93.21%) relate to the primary care services of GPs, hospitals and dentists. While this is unlikely to present issues respecting the general trends examined, more specific comments relating to these areas might be said to be over-represented compared with other areas of service provision, such as care providers and mental health trusts. Moreover, the data analysed in this study represent feedback given in one specific form (online comments), posted to one particular website (NHS Choices), about organisations based in one country (England). This raises issues surrounding representativeness; for those who choose to share their experiences online are not necessarily representative of the general population. It is now well documented that, compared with non-internet users, internet users tend to be younger, are more educated and are from higher income brackets.30 Although this digital divide is estimated to have narrowed over time,11 the perspectives of people from these so-called ‘hard-to-reach’ or ‘seldom-heard’ groups are still likely to be under-represented in our data.8 31

Strengths and weaknesses in relation to other studies and important differences in results

Where a great deal of existing research has explored patient feedback in terms of predetermined themes, the data-driven approach adopted in the present study has allowed drivers of feedback to emerge from the comments themselves throughout the course of the analysis. As a consequence, system and organisation issues, which have remained largely unexplored in existing research, have emerged here as significant drivers of positive and negative evaluation with respect to various other aspects of care, including quality of treatment and staff communication skills.

As well as providing fresh insight into the perspectives of patients accessing contemporary healthcare services in England, the findings reported in this study also provide more substantive quantitative evidence to support the findings reported in existing studies of patient feedback that are based on comparatively smaller and older datasets.32 33 However, our findings highlight the centrality of interpersonal skills as a key area of concern in its own right and as significant to the ways that treatment quality and staff communication are evaluated.

Meaning of the study: possible explanations and implications for clinicians and policy makers

While the majority of research into patient feedback has focused principally—in most cases exclusively—on what motivates negative feedback, the present study has elucidated the drivers of positive and negative feedback equally. Accordingly, while the reported drivers of negative feedback might flag up areas that require attention, the specific drivers of positive feedback outlined over the course of the analysis offer insight that can be used to stimulate and guide quality improvement efforts.34–36

The quantitative section of our analysis suggested system and organisational issues to be a prominent theme in negative feedback. This often relates to issues surrounding accessibility of care, such as (emergency) appointment availability, waiting times, technical difficulties experienced with online booking systems, telephone waiting times and practice opening times. Tightening government expenditure in healthcare provision and resultant constraints on practitioner time and availability mean that these issues are unlikely to abate. Such issues arguably lie within the remit of policy makers and governing bodies. However, practitioners and other staff can improve patient feedback in this area by making an effort to ensure that appointments run on time and informing and updating patients and their families in the case of cancellations or delays.

The qualitative section of our analysis suggests that staff interpersonal skills lie central to improving care, as these were shown to motivate negative (and positive) feedback in relation to a variety of areas of concern. On the surface, the findings of this study suggest that developing the interpersonal skills of staff should be a priority in staff training. The interpersonal skills of both medical and non-medical staff were evaluated positively for qualities such as being friendly and approachable, empathetic, for smiling, and not being afraid to laugh and joke with patients. Allied to this, practitioners were frequently positively evaluated for providing care that was patient centred and involved discussing treatment options with patients, as well as explaining treatment plans and listening to their concerns. Conversely, staff were negatively evaluated when they were perceived as being rude, dismissive, lazy, not listening to patients’ concerns, as well as for not smiling and appearing unhappy.

Most professional medical training (eg, in medicine and nursing) includes the development of communication skills as a key element at the undergraduate level and onwards. This kind of interpersonal training is often focused on developing skills such as  information gathering and shared decision making. Our findings suggest that, as far as patients are concerned, the interpersonal aspect of interaction is given a high premium. Such skills might be developed more effectively through greater opportunity for hands-on human engagement, rather than instruction alone, at the early stages of training. In terms of developing the interpersonal skills of other non-medical staff groups, it is likely that many staff working in administrative capacities, such as receptionists, will not have received formal training in interpersonal skills (although healthcare providers are increasingly running courses in ‘customer service’ to address this). Likewise, there is an intermediate group, which includes staff working in healthcare assistance, who may have received limited or no formal training, but who nonetheless engage with patients at very significant levels and may benefit from some form of interpersonal skills training.

However, many of these specific interpersonal or ‘soft’ skills can be linked to the concept of emotional labour,37 which involves the regulation of emotion to create a publicly visible facial and bodily display within the workplace. These kinds of attributes might seem more like individual character traits, and so incorporating these into training poses challenges, especially as members of the public are often unimpressed by ‘scripted’ interactions which are rightly seen as inauthentic.38 Soft skills training, while clearly helpful in some areas, may sometimes be a ‘sticking plaster’ solution to cover for wider structural problems involving overstretched systems. Other positively evaluated interpersonal aspects of care, such as involving patients in communication and decision making and ensuring that patients have sufficient time to interact with medical staff and are not made to feel as though they are ‘rushed,’ might constitute more tangible and attainable targets for skills development programmes.

In an effort to stimulate such improvements, the findings from the project from which this research derives, including the results reported in this article, have been presented to the Insight and Feedback Team at NHS England as well as the Care Quality Commission in the UK. However, in reality, translating such findings into practice is seldom straightforward. After all, although most major public sector healthcare providers collect feedback on their services at least annually, this information is not always used to improve service quality.3 Suggested reasons for this include a lack of attention to patients’ experience at senior levels,39 as well as feedback data not being specific to particular wards or teams.40

As well as gesturing towards areas for improvement in healthcare provision, the findings reported here also provide insights into patient feedback more generally; insights that likely bear implications for how such feedback should be interpreted in the future. Our quantitative examination of the data revealed significant overlap between the drivers of positive and negative feedback. As an example, although treatment fared best of these four themes of feedback in terms of positive evaluation, it was only by examining the comments relating to treatment that we were able to show that 47% of the positive comments relating to this theme actually praised interpersonal aspects of care, rather than the technical competence of staff, which accounted for only 10% of these comments. It is therefore beneficial, where possible, to gauge feedback at a granular level. This is where combining quantitative and qualitative approaches can bear significant advantages for researchers, allowing us to deal with large datasets in a way that is sensitive to subtle nuances and overlaps and to  point to specific areas for praise or improvement that only become apparent at the more granular level.

Unanswered questions and future research

Although the data contain feedback relating to a variety of healthcare organisations, such distinctions have not figured in the analysis undertaken in this study. Future studies on this particular dataset should therefore take a modular, even comparative approach, to ascertain similarities or differences in the ways that care is evaluated in each of these areas. Furthermore, we did not have access to the demographic information of the comment posters. Future research should endeavour to collect and examine data that comprise this kind of demographic metadata in order to determine whether particular concerns are attributable to people living in certain locations or belonging to particular age, ethnic or sex-related groups. Future research should also assess feedback given in other, particularly non-digital, mediums in order to help account for the perspectives of patients from ‘hard-to-reach’, ‘seldom-heard’ groups who might be less likely to give feedback online. Ziebland and Coulter8 recommend that non-traditional methods of data collection, such as pictures, stories and drama, might be used to incorporate the views of such groups in future feedback collection exercises.