Published 17 March 2009, doi:10.1136/bmj.b1030
Cite this as: BMJ 2009;338:b1030

Head to Head

Will doctor rating sites improve standards of care? Yes

¹ Summertown Pavilion, Oxford OX2 7LG

The UK government has signalled its support for rating sites with the decision to set up its own through the NHS Choices website. Neil Bacon believes they provide essential feedback for doctors, but Margaret McCartney (doi:10.1136/bmj.b1033) is concerned that the potential harms are still unclear

Patient experience is a key component of the measurement of the quality of care we deliver.¹ Thus no individuals or organisations can know they are delivering high quality care without a full awareness and understanding of the experience of their patients—it would be like caring for a patient with a kidney transplant without knowing the creatinine concentration.

Unfortunately, doctors are known to be poor judges of their patients’ satisfaction and experience,^{2 3 4} and at an organisational level it is probably even worse. Acute trusts score a mean of just 0.68 out of 10 for how much they ask for the views of their patients.⁵ In effect, most doctors and NHS healthcare organisations are "flying blind" with respect to the experience of their patients—hardly a patient centric, or professional, way to deliver health care. Worse than that, it is not an effective or efficient way to care: key clinical measures and outcomes are related to patient satisfaction.^{6 7 8} An excellent patient experience and great clinical skills are required to do the very best for patients.

Need for information

The problem is that existing ways of measuring the patient experience are ineffective in helping professionals get an accurate and detailed understanding of their personal ability and effectiveness in this respect. Indeed, most UK doctors get no regular, structured feedback on the experience of those they care for. Likewise, assessments of an organisation’s performance based on occasional, paper based surveys or focus groups (the preferred method of the Healthcare Commission) do not correlate with patients’ ratings of their care.⁹

Lessons from a myriad other industries and professions show that improved individual and organisational performance is absolutely dependent on valid, timely, detailed feedback.¹⁰ The same is true in medicine—systematic feedback changes doctors’ clinical performance,¹¹ and real time assessment and feedback of doctors improves clinical performance.¹² Good doctors are aware—from the literature and observing colleagues—that a poor doctor-patient relationship equates to poor patient experience and often poor clinical outcomes. Such care is not only unsettling and upsetting for both those receiving and delivering care, but is also a strong predictive factor for litigation.^{13 14} The majority of doctors strive to do an excellent job and welcome valid, robust tools to support continuous self improvement. Such support requires individual data, not an average score for the whole department or practice. After all, which surgeon would find an average infection rate for her hospital helpful in the pursuit of personal excellence?

In order to fully engage patients in this process, and thereby generate the high level of feedback needed, patients need to see the impact and benefits of their feedback. Web based, open feedback enables this visibility in the most powerful, immediate, and involving way.

Far from causing fear among patients, or causing doctors to avoid "difficult" cases, evidence shows that such openness leads to increased trust between doctors and those they care for, and a relentless increase in quality health outcomes.¹⁵ There is no better way of ensuring transparency, engagement, and dissemination than using the web to capture and share patients’ accounts of their experience.

Managing data

It is inevitable that the web will have a role in collecting and disseminating data on patient experience given the information age in which we live. For a minority of doctors to suggest that patients should somehow be prevented from benefiting from the transparent, internet enabled feedback that has done so much to improve standards and quality in other industries¹⁶ is a throwback to a medical paternalism that most of us thought was long gone. And let’s be clear, it is never patients who argue against properly organised and robust internet services to allow them to feedback on, and search for, high quality health care. Indeed, there is a strong and growing demand from patients to be able to use the internet to find reliable information about the health care on which they depend, and for which they pay.¹⁷

Users of health care will increasingly voice their opinions on the internet, but scattered, unorganised, uncontrolled comment across hundreds of different sites is unhelpful to doctors and confusing (or even dangerous) for our patients. The profession therefore has a responsibility to take a constructive and leading role in developing quality doctor rating sites that can best benefit both professionals and the public. Done properly (including robust systems to protect doctors from the abuse of mad, bad, or infatuated patients) such sites can bring together a critical mass of real time, granular, qualitative and quantitative feedback, providing new insights on the perceptions and needs of our patients.

Web based feedback is standard in many other industries, but it is a new tool to medicine, and there are of course issues still to be debated and questions to be answered: should reviews be anonymous, would doctors want or use the ability to respond to comments, and how to integrate this information with other data sets? However initial experience in the UK (iWantGreatCare, first 2000 reviews) shows that well managed, professionally responsible rating sites represent no risk to good doctors and are highly popular with patients.

Such sites will improve standards of care—but only for those organisations and doctors that think the experience of the patient is as important as excellent clinical outcomes and are prepared to transform the organisation and delivery of care in a way which fully harnesses the experience of the patients they serve.

Cite this as: BMJ 2009;338:b1030

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Competing interests: Neil Bacon is a doctor and the founder and majority shareholder of iWantGreatCare.

References

1. Darzi A. High quality care for all: NHS Next Stage Review, final report. London: Department of Health, 2008.
2. McKinstry B, Colthart I, Walker J. Can doctors predict patients’ satisfaction and enablement? A cross-sectional observational study. Fam Pract 2006;23:240-5.[Abstract/Free Full Text]
3. Shannon SE, Mitchell PH, Cain KC. Patients, nurses, and physicians have differing views of quality of critical care. J Nursing Scholarship 2002;34:173-9.[CrossRef]
4. Zachariae R, Pedersen CG, Jensen AB, Ehrnooth E, Rossen PB, von der Maase H. Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. Br J Cancer 2003;88:658-65.[CrossRef][Web of Science][Medline]
5. Healthcare Commission. NHS Annual Health Check, 2007. London: Healthcare Commission, 2007.
6. Winefield HR, Murrell TG, Clifford J. Process and outcomes in general practice consultations: problems defining high quality care. Soc Sci Med 1995;41:969-75.[CrossRef][Web of Science][Medline]
7. Jha AK, Orav J, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med 2008;359:1921-31.[Abstract/Free Full Text]
8. Howell E, Graham C, Hoffman A, Lowe D, McKevitt C, Reeves R, et al. Comparison of patients’ assessments of the quality of stroke care with audit findings. Qual Safety Health Care 2007;16:450-5.[CrossRef]
9. Ipsos MORI Social Research Institute. Frontiers of performance in the NHS II. London: Ipsos MORI, 2008.
10. Kaplan RS, Norton DP. The balanced scorecard—measures that drive performance. Harvard Business Review 1992 Jan–Feb:71-9.
11. Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. Systematic review of the literature on assessment, feedback and physicians’ clinical performance. Med Teacher 2006;28:117-28.[CrossRef]
12. Caldwell G. Real-time assessment and feedback of junior doctors improves clinical performance. Clin Teacher 2006;3:185-8.[CrossRef]
13. Kinnersley P, Edwards A. Complaints against doctors. BMJ 2008;336:841-2.[Free Full Text]
14. Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D, et al. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA 2007;298:993-1001.[Abstract/Free Full Text]
15. Gawande A. The bell curve. What happens when patients find out how good their doctors really are? New Yorker 2004 Dec 6.
16. Cook S, The contribution revolution—letting volunteers run your business. Harvard Business Review 2008 October http://hbr.harvardbusiness.org/archive-toc/BR0810.
17. Bright B. Public interest in rating and using consumer ratings of doctors. Wall St Journal 2008 Feb 23. http://online.wsj.com/article/SB120292044107465659.html?mod=home_health_right.

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This article has been cited by other articles:

• Hodgkin, P. K (2009). Web based patient feedback. BMJ 338: b1377-b1377 [Full text]  

Rapid Responses:

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rating sites as an educational tool

chris harnden
bmj.com, 19 Mar 2009 [Full text]

Nonsense

Martin J Toal
bmj.com, 23 Mar 2009 [Full text]

Feedback is good: iwantgreatcare.org is not

Dominic H R Faux
bmj.com, 22 Mar 2009 [Full text]

Web-based patient feedback is coming

Paul K Hodgkin
bmj.com, 23 Mar 2009 [Full text]

Simple problems, require simple solutions.

David R Warriner
bmj.com, 25 Mar 2009 [Full text]

Some doctors will avoid high-risk patients

Nicos Kessaris
bmj.com, 1 Apr 2009 [Full text]

It's better than no ratings

C Fezziwig
bmj.com, 1 Apr 2009 [Full text]

Basis for assessment

Joan McClusky
bmj.com, 2 Apr 2009 [Full text]

Patient feedback is important but

Umesh Prabhu
bmj.com, 3 Apr 2009 [Full text]

Are we ready?

Sukhpal S Gill, et al.
bmj.com, 4 Apr 2009 [Full text]

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