Head To Head

Will doctor rating sites improve standards of care? Yes

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1030 (Published 17 March 2009) Cite this as: BMJ 2009;338:b1030
  1. Neil Bacon, founder, iWantGreatCare.org
  1. 1Summertown Pavilion, Oxford OX2 7LG
  1. info{at}iwantgreatcare.org

    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


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