Limitations of study

There are a number of limitations to this study. First, an analysis based on one year's surveys might limit the generalisabilty of the findings, as patterns may differ across repeat surveys. However, while results for individual organisations may improve or worsen between surveys, the overall pattern of performance across trusts typically does not show marked changes in year on year performance.8 Second, it was possible to use only a limited number of trust-level characteristics; other organisational-level factors could also be associated with variations in patient experience. Third, it could be argued that differences in the number of questions in each domain have an impact on the pattern of variations observed across domains. However, the results provide no indication of differential patterns between domains according to the number of constituent questions. Additionally, we retained domains (such as involvement in decisions) with fewer relevant questions because they represent important aspects of care and are defined by questions that are the same/similar across surveys. Finally, the experiences reported by patients, and of non-respondents, could be influenced by many factors—related or unrelated to the quality of care. These factors could potentially impact on the survey results. Examples include response bias associated with differential response rates (the direction of response bias is not known but it could systematically impact on the results); language differences between trusts' patient populations that could, for example, make involvement in decisions more difficult; differential impact of trust location; urban–rural residence, case mix of patients etc. The direction and magnitude of impact of such factors (and potentially others) is not known, and could potentially influence the survey results and therefore also the results of our analysis. These examples illustrate the complexities of and challenges in measuring patients' experience of care. Nonetheless, we consider it important to make maximum use of the available data.

Strengths of study

Patient experience is internationally recognised as a key dimension of healthcare quality, and a priority for the NHS identified by successive governments in England. The surveys capture patients' feedback on their experiences of NHS services, and are the leading source of information on this key dimension of NHS performance. However, the use of these rich data for quality improvement purposes has not been fully exploited because of the compartmentalised approach taken thus far in the analysis and use of these datasets.

Our paper adds value by taking a systems perspective to examine whether there is consistency in the way patients experience care across services within an organisation, and if so, what might characterise trusts that demonstrate levels of excellence. Our findings about the scale and patterns of variations in performance across trusts have significant implications for quality improvement initiatives in the NHS. They also have significance for commissioners, regulators and policymakers in terms of their system-wide roles. Given that the unprecedentedly large samples of the NHS patient surveys provide unique opportunities for research, the general messages could also have relevance for healthcare systems elsewhere.

Interpreting the findings

The hypothesis that there should be some correlation between performance measures within organisations is grounded in systems theory, which implies that the culture of the system permeates all areas of operation.9 Thus organisations driven by a culture of excellence would be expected to have positive patient experience across all areas, while organisations that have not established such a culture would be expected to have consistently poor performance.

Our analyses overall suggest that there is a degree of consistency in trusts' performance in terms of the experiences of their service users. We found statistically significant correlations between performance on the different surveys, the correlations being strongest for the cleanliness and dignity and respect domains—aspects of quality where a pan-organisational approach may be more readily driven from board level.

Overall, the cluster analysis revealed patterns of consistent performance across surveys and domains, with some trusts appearing consistently in above or below average performance clusters on all domains and service areas (21% and 4% of trusts, respectively). The domains with the largest number of trusts (almost 60%) in the best performing cluster were dignity and respect, and consistency of communication; in contrast, for provision of information, almost one-third of trusts were consistently in the poor performing cluster. These findings suggest that there are system-wide determinants of patient experience, with some organisations being consistently high performing—either overall across surveys, or in certain dimensions such as cleanliness and dignity and respect—and others that lack a culture and mechanisms for delivering a good experience for their patients.

Overall, the distribution of trusts is skewed towards better performance. However, the survey results overall show considerable room for improvement (mean domain scores being well below the maximum of 100). About 65% and 70% of trusts, respectively, were in the below to average performance clusters for the involvement in decisions and confidence in staff domains, and up to half of trusts for the remaining domains.

We found that teaching and foundation trust status showed an almost consistently positive association with performance across domains. This finding is consistent with other recent research10 and suggests that such organisations may have implemented patient-focused strategies more effectively than others. A review of the performance of foundation trusts suggests that they outperform non-foundation trusts in areas such as staff satisfaction, financial management and quality of care, but that the differences are longstanding rather than the effect of the foundation trust policy per se.11 (Performance on the patient surveys could, of course, have contributed to achievement of foundation status.) Foundation trusts are also generally reported by their regulator, Monitor, to have better clinical quality and service performance than non-foundation trusts.12 These patterns are consistent with our findings.

The proportion of the inpatient population that was white was also positively associated with patient experience, consistent with other research showing that people from black and ethnic minority groups often report a less favourable experience of NHS services than white respondents.10 13–15 This could reflect aspects of service delivery that need improvement in trusts with higher proportions of patients from ethnic minority groups. For example, language and communication problems can impact negatively on patient experience.16 Until the change of government in 2010, the Department of Health's Public Service Agreement target on patient experience, for which it was accountable to the Treasury, extended to improving patient experience for ethnic minority groups. NHS policies and equality legislation continue to require providers to meet the needs of all groups of patients. Trusts therefore should identify ways of meeting the particular needs of patients from black and ethnic minority groups, including through greater engagement with patient groups representing these communities.

The weak but positive association of deprivation with patient experience could reflect lower expectations of the NHS among patients from poorer socio-economic groups: alternatively, this may reflect differences in the patterns of interactions between people of different social classes with healthcare services and professionals. Other research found a negative association between social class (measured as respondent age at completing full-time education) and reported patient experience, which is consistent with our findings in relation to deprivation.14 15

Although none of our high-performing cluster included London trusts, and although the poor performing cluster consisted entirely of London trusts, we found no regional effects after adjusting for the independent variables. Ethnic ‘fractionalisation’ (heterogeneity) and low response rates are often cited as explanations for the comparatively poor survey results for London trusts,17 and inclusion of these variables in the regression analysis could explain the lack of a residual regional effect. However, as noted above, trusts should be addressing the needs of ethnic minority patients: population differences should never be seen as an ‘excuse’ or ‘justification’ for poor patient experience, even if these differences do mean that some trusts face different challenges in understanding and meeting the needs of their populations. Another possibility, given the association between response rates and survey scores, is that lower response rates in London—attributable to particular local characteristics such as a more transient population—might somehow mitigate against higher survey scores. However, as the scale and direction of any potential response rate bias is unclear, and given the lack of evidence about causality in regional effects, we do not consider these factors should be adjusted for in the analysis and interpretation of data from patient surveys.

Implications for improving and measuring patient-centred care

Our study has important implications for quality improvement and measurement. Overall, it is encouraging that trusts are clustered towards better performance. However, this should not lead to complacency, as the findings also show considerable room for improvement. Strategies are needed for raising poor performers to the levels of the best, and for moving the whole performance distribution upwards. The finding that some NHS providers consistently perform better than others in delivering a good experience for patients suggests that there is potential in learning from these innovators.

Based on the organisational factors that distinguish hospitals able to deliver patient-centred care, Shaller identifies seven factors contributing to patient-centred care18:

1. Engagement of the top leadership.

2. A strategic vision clearly and constantly communicated to all staff.

3. Involvement of patients and families at multiple levels.

4. A supportive work environment for all employees.

5. Systematic measurement and feedback.

6. The quality of the built environment.

7. Supportive information technology.

Shaller also identifies the key strategies for leveraging change as those designed to strengthen the capacity to achieve patient-centred care at the organisation level, and those aimed at changing external incentives in the healthcare system, to influence and reward organisations striving to deliver patient-centred care. The NHS reforms provide opportunities for taking forward such strategies through the commissioning outcomes framework and quality premiums, with the new clinical commissioning groups using contracts and pay for performance schemes such as Commissioning for Quality and Innovation (CQUIN) as additional levers.

Luxford et al's investigation into organisational facilitators and barriers to patient-centred care among US healthcare providers renowned for improving patient experience found that organisations that succeed in fostering patient-centred care adopt a strategic organisational approach to patient focus.19 The facilitators they identified were largely consistent with those identified by Shaller. The barriers were changing staff mindsets from a provider focus to a patient focus, and culture change as a journey rather than a ‘quick fix’. They highlight the need for an organisation-wide approach and culture that goes beyond mainstream frameworks for quality improvement, such as performance measurement, audit, risk management systems, incident reporting and clinical governance, to becoming a learning organisation with a culture that values people, stimulates ideas, develops teamwork and adopts staff recognition systems. The association between the self-reported experience of NHS staff and patients20 is further evidence of the need to engage the workforce in a culture that fosters patient-centred care.

Goodrich and Cornwell's review of the literature on patient experience notes that evidence about organisations reputed for providing excellent patient care shows that it means transforming hospital cultures and working practices, a complex task requiring investment at both strategic and operational levels.21 They note that patients' experience is shaped by organisational and human factors interacting in dynamic, complex ways at four levels: individual patient–staff interaction, the team and clinical micro-system, the institution and the wider health system.

This framework serves to highlight a key constraint of the national survey programme. Goodrich and Cornwell highlight the crucial role of local ward, team leadership in modelling patient-centred care behaviours and defining expected values and behaviours of team members. While the surveys provide valuable organisation-level information for accountability and transparency purposes, and for senior management to act on, they are not designed to provide intra-organisational data. Their practical utility as an improvement tool for frontline staff in particular is therefore constrained because the sample sizes do not allow disaggregation of the data to a granular level, such as ward/clinical teams. The national survey programme does therefore need to be supplemented locally by other mechanisms for collecting and using such data. While highlighting the general paucity of evidence about effective interventions for improving patients' experience, Goodrich and Cornwell do identify some interventions designed to achieve system-level change.

Finally, the key is the use of the patient survey data for improving patients' experience of care. Reeves and Seccombe found that the surveys are widely used by trusts for these purposes, but key constraints included the lack of clinical engagement because the surveys do not extend to specialty or department level, and inadequate resources, statistical expertise and knowledge of effective interventions.22 Their findings about the role of leadership, organisational culture, incentives, benchmarking, public reporting, and internal drivers are consistent with the other research cited. Coulter et al point to a lack of systems for coordinating the collection of patient feedback and acting on the results. They suggest a strategy for improving patient experience that cuts across organisational levels (from the Board to clinical departments) and stress the role of strong leadership.23

Our study also shows that appropriately constructed composite measures have utility in summarising performance across quite lengthy questionnaires about patient experience. Some composite measures are already in use in the NHS for pay-for-performance schemes such as CQUIN.24 However, composite measures are more complex for staff, patients and the public to understand. We stress that, if used, composite measures should be based on rigorous statistical analysis to assure the robustness of the constructs. While composites provide convenient summary measures, scrutiny of responses to individual questions is critical for targeting improvement actions. In addition to analysing the various patient surveys separately, there is merit in benchmarking performance in the round across all surveys at an organisational level. Finally, local data collections (such as ward-level patient feedback) are a timely and valuable supplement to survey data for understanding and improving patient experience at the service level.

We hope that our findings will encourage trusts to examine their performance across the different patient surveys to see how they perform overall. This could help drive improvements by learning from the better performing parts of their organisation, and cross-trust collaboration to promote learning from exemplars. Our finding about the need to improve performance levels overall, coupled with the evidence about organisational factors that facilitate the development and implementation of patient-focused care, suggest that improvement strategies need to be undertaken by providers and the healthcare system as a whole.