Intended for healthcare professionals

Rapid response to:


Friends and family test should no longer be mandatory

BMJ 2018; 360 doi: (Published 29 January 2018) Cite this as: BMJ 2018;360:k367

Rapid Response:

Re: Friends and family test should no longer be mandatory

FFT has certainly been used and abused and is often misunderstood. It has also generated a mini-industry around itself which will make a strong argument for retention. As a headline performance metric, let alone a quality metric, FFT is certainly flawed and the focus on high response rates has been both a distraction and arguably posed an unnecessary burden. However, it is the actions taken as a result of any patient feedback that should be a true measure of its success but as this isn’t easily quantified in a meaningful way and doesn’t comfortably fit into a dashboard or graph it is harder to ascertain or measure with any certainty.

As the respected authors of this article have recognised the real value is in understanding and making improvements as a result of qualitative comments from patients indicating why they have had either a very good or a very bad experience of health care and not the bulk in the middle that have had an OK experience and are generally happy. While statisticians will focus on how typical these extremes are the key thing is to capture specific themes to understand why and what can be done at an individual patient level as well as more broadly and to see how they change over time as well as to triangulate them with other quality metrics (patient safety, complaints, staffing) wherever possible. How typical the responses are from different population groups is not possible to judge as patient demographic information is usually minimal and no follow-up is possible as individuals are anonymous so other patient feedback methods are certainly needed to produce more granular material on the back of FFT and to ensure all groups are heard. FFT is certainly not a panacea but it can provide an indication of what patients are experiencing close to “real-time” which is not possible in more detailed national surveys.

While value versus the cost of collection is clearly an important consideration there appears to be an assumption being made here that the resources currently being devoted to FFT will automatically be re-focussed to what is being suggested are more productive locally-generated schemes. Is this likely or will they be re-assigned to other pressing NHS priorities? Maybe it is most likely funds will be re-directed to other patient experience schemes where there is already a strong culture of clinical engagement and participation in patient experience work but not necessarily where this doesn’t exist so current differences in practice will be exacerbated.

One of the key things with FFT has been to ensure patients are actively encouraged to share their experience, where they may not previously have done so, and for clinicians to welcome constructive feedback. Some people assumed that the strongest motivation would be from those that had a bad experience which has not proven to be the case. At the same time front-line staff have been able to use patient feedback in support of improvement and good practice has been recognised although inevitably greater focus is on fixing what has not gone well rather than recognising a job well done.

Abandoning FFT could very well reduce activity around understanding patient experience rather than freeing up resources to enhance it. In the same way a case has been made to abandon the Inpatient Survey on cost versus value grounds not because it doesn’t provide valuable comparative data, because it is does, but on account of the lack of overall improvement and arguably clinical engagement and therefore change in practice that has been made on the back of it versus the cost of collection since it was introduced. This survey is very unlikely to be withdrawn.

Clearly, the best locally-based patient experience schemes and surveys are of the highest value, where they are properly administered, and where there is consistent leadership and strong clinical support and input behind them. The question is really whether FFT is the main impediment getting in the way of advancing in this direction? And while I commend the overall ambition of the authors; are they really suggesting that those who are currently paying lip-service to FFT, doing nothing or the bare minimum with the qualitative comments and themes and little else on patient experience, will suddenly be at the front of the queue to adopt more innovative local patient feedback schemes if FFT was abandoned? Can I suggest that what is being proposed is brave in concept but potentially foolhardy in practice.

Competing interests: No competing interests

30 January 2018
Paul Carter
Quality manager
NHS England