Patient Feedback Line Pilot Provides Valuable Insights

1Customer Insight Public information
Patient Commenting:Telephone Feedback Line Pilot
- Qualitative Research
15th February 2013

Patient Telephone Feedback Line Pilot –
Research Report: Table of Contents
3 Background and Objectives
5 Research Method
6 Key Learnings
7 Executive Summary
11 Definition of Feedback
17 Feedback on NHS Services
23 Evaluation of Telephone Feedback Line
31 Communicating the Feedback Line
35 Next Steps

Background
• The NHS Choices website currently gives the opportunity for customers to
give feedback on their service experiences. The most recent performance
report suggests the number of comments left appears to be levelling out at
around 5,000 per month across all NHS services.
• On-line feedback appears broadly in-line with other service sectors that
encourage customer comments and is similarly skewed towards younger,
female, higher SEGs. Preliminary research among a nationwide sample of
adults indicates that while on-line feedback is the preferred channel for half of
those interviewed, for a third of users, an opportunity to leave comments via
the telephone would be the preferred option.
• To extend reach, the NHS is in the process of piloting an 0800 number on the
NHS Choices website that will allow users to give comments directly to an
operator. The Customer Feedback Line will extend the opportunity to provide
and potentially encourage feedback from NHS customers in groups that are
harder to engage on-line.

Research Objectives
A research programme was designed to:
• Explore consumer attitudes to providing feedback comments in general
• Understand drivers for commenting and expectations of what will happen
as a result i.e.
• How does commenting on NHS issues differ from feedback in other sectors?
• Determine the impact of channel on the willingness to provide feedback
and on the type of feedback provided
• Evaluate the telephone line user experience with opportunities to improve
• Explore circumstances when customers would consider using telephone
to comment
• Explore how and where should the service be publicised to maximise
reach
• Who would use it and why?
• Understand customer expectations of what will happen following their call.

Research Method
• 4 x 1.5 hour focus groups with NHS users that have never provided
feedback via NHS Choices
• Groups were split by experience of commenting
• 2 groups had not fed back / commented by any means in the last 12
months
• 2 groups had provided feedback for goods/services but not about NHS
services
• And age
• 2 groups aged under 40 years of age
• 2 groups aged 40+ (including at least 2 retired)
• Groups were mixed gender and ethnic background
• Half the groups were held in a viewing studio, half in-home
• 2 groups were held in Merton: current 111 pilot area
• Group respondents were pre-tasked to call the phone line and leave a
comment on a recent NHS service experience
• 4 x 30 minute telephone interviews were held with NHS users who
called the feedback line after seeing a pop-up on NHS Choices

Telephone Feedback Line Pilot
- Three Key Learnings
 ‘Feedback’ is defined by the general public by organisations like
Amazon and Ebay - They do not understand the benefit of providing
feedback within the NHS
 There is no clear motivation for NHS Users to provide feedback on
services - They do not believe patient feedback can influence change or
help patient choice within the NHS
 A Telephone Feedback Line will bring in some additional
commenters - But without communicating how and why consumers
should use it, risks being dominated by potential on-line commenters,
complaints and information requests

Telephone Feedback Line Pilot – Executive Summary
- Nature of Feedback
• Commenting and on-line reviews of products and services have become an accepted part
of on-line relationships with suppliers. Led by Amazon, Ebay and sites such as TripAdvisor
even non-commenters are likely to check customer feedback as part of their own purchase
decisions.
• Younger consumers have generally bought into the benefits for both individuals and the
wider community of using and sharing comments. Older generations (60+) are less likely to
be actively involved in feedback but recognise the value of other people’s opinions via
established reviewers like Which or general word of mouth.
• NHS customers, accept, in principle, that a similar model for logging and posting
customer feedback and reviews could be established for NHS services. In practice, this is
inhibited by fundamental perceived differences between an NHS provider/patient relationship
and a commercial supplier/purchaser relationship. Patient/NHS partnerships have stronger
emotional and personal elements that do not fit neatly into the familiar feedback model.
• There is a need to educate NHS users of the end benefits of sharing and using patient
comments to encourage participation. Expectation of achieving service improvements via
patient feedback is currently low.

• There is currently low perception of patient choice within the NHS that will drive customers
to search or post feedback. There is a strong belief that choice of GP and hospital is beyond their
control therefore there is no recognised requirement to search for reviews and recommendations .
• Providing a telephone feedback service risks attracting users that may have otherwise
posted comments on-line - particularly among older consumers. Speaking to someone, gives
confidence that comments are ‘listened to’.
• A telephone option may attract new commenters that would perhaps not have left feedback
at all. Customers that intended to leave comments, but never got round to it, may be prompted to do
so by a telephone number.
• A telephone feedback line needs clear signposting to minimise use as a channel for
complaints. Customers naturally differentiate feedback from ‘complaints’ that require a formal
response, paper trail and resolution. NHS users would not generally use a telephone service for
this, but may use the channel to kick start the process.
• Older NHS users, in particular, have difficulty in differentiating negative feedback (to assist
other NHS users with choices) from complaints. This group requires educating that ‘constructive
criticism’ is valuable to the wider NHS community and will improve, not damage, ‘their NHS’.
- Feedback On NHS Services

- Use of the Telephone Feedback Line
• There are concerns across customer groups of the likely fallout from leaving negative
feedback on local services. Feedback on purchases/services in general is considered
impersonal and anonymous. There are worries that leaving feedback on local hospitals, GPs
and dentists may have repercussions next time they visit.
• The Telephone Feedback Line was overall, considered well staffed and simple to use.
Where it worked well, the process was short, clear, and provided satisfaction for users that their
comments had been listened to and recorded accurately
• Call handlers are attentive, personable and willing to help even when faced with
problems with the system. They were not considered or expected to be ‘medical experts’ but
vastly exceeded expectations from a central call-handling facility
• Call handlers had difficulty in locating some hospitals/practices at the beginning of the
call causing delays and frustration for users. Operators are reliant on the information given
by customers to identify targets for feedback. Call handler training on managing searches will
correct some issues, although evidence indicates that details of service providers are not always
up to date.

• The request for demographic classification information was considered by some users to be
intrusive and the necessity questioned. Asking about ethnic background and age in particular
concerned some respondents, especially when asked at the beginning of the feedback process. The
need to leave a telephone contact number also caused unease.
• Accessing the pilot telephone line via mobile phone was expensive (14p per minute). Coupled
with delays caused by inability to locate the target feedback location, completing demographic details
and checking content, users viewed the service as an expensive means of leaving feedback.
• NHS users interviewed in the focus groups had very low/no awareness of the NHS Choices
website. They were therefore not aware of an existing ‘NHS information sharing community’ in the
context of which commenting on their own experiences may seem more relevant
• Respondents believed that communication of the feedback line should be at local points of
service and messages should be rooted in ‘your NHS’. Service users appreciate the benefit of
sharing their experiences if they can see it will impact on improved services for the local community
• NHS users do not see themselves as ‘customers’. They expect language used in communicating
the Feedback Line to be appropriate to their relationship with NHS services. They wish to hear that
the NHS is ‘listening’ to patient opinions for the benefit of the wider NHS user community.
- Publicising the Telephone Feedback Line

Definition of Feedback

Feedback is ‘a chance to give a personal
opinion’
Individual definition of
‘feedback’ determines
motivation to
comment, level of
engagement, content
and expectation of
outcome
Influenced by
demographics, internet
activity, feeling of social
responsibility and
desire to be heard
“response”
“good experience”
“complaint”
“constructive criticism”
“chance to improve service”
“a rant”
“a thank you”
“praise”
“grievance”
“dissatisfaction”
“satisfaction”
“endorsement"
“warning to others” “venting”
An unprompted opportunity to give feedback will skew towards those holding
strong feelings and/or those that already buy into the idea of a ‘feedback loop’
By nature people tend to
moan more than they
would say ‘thank you’
(female 40+)
“helps other users”

Feedback is associated primarily with on-line
commercial websites
Used to check out goods before purchase:
More reading than posting feedback
Providing feedback fundamental to buyer and
seller ratings. Incentive to feedback
Useful research tool. Exceptional experience or wish to
‘balance’ negative comments triggers posts
• Feedback/reviews part of a
website culture
• High awareness even
among ‘non-commenters’
Banks
Mobile phone providers
Restaurants
Feedback requests from retail/service providers are treated more sceptically…
• Just ticking boxes
• Not really listening
• Doubts will lead to service improvement
Definition and credibility of ‘feedback’ varies according to the organisation that requests it. Customers
are more likely to engage where feedback is considered to be intrinsic to the customer experience and
benefits, either personal or for the wider community, are recognised

Purpose of ‘feedback’ determines
expectations of outcome and channel used
Complaint
Feedback
positivenegative
Praise
•Personal
•Emotional
•Considered
•Address to individual (or)
•Proof reaches individual
•Small Gift/‘thank you’
•In person
•Letter/phone call
•Personal
•Emotional
•Considered
•Address to individual (or)
•Head of organisation
•Paper trail required
•Response essential
•Email
•Or Letter (older) •Venting
•Warning to others
•Impersonal
•Publication expected
(younger)
•Usually prompted
•No response required
•Generally on-line
•Express satisfaction
•Support for service
•Impersonal
•Wish to be counted
•Publication expected
(younger)
•Usually prompted
•No response required
•Generally on-line
Complaints carry a greater momentum and will be initiated by any channel available –
including a feedback line. On-line commenters just hope feedback will ‘filter through’
A complaint is more
between you and the
institution whereas
feedback is usually in a
public forum
(G1: commenters ≤ 40 y/o)

Engagement in feedback depends on a
persuasive reason to participate
What will be achieved?
Who will benefit?
Change in service
Change in behaviour
Self
All users/customers
Unlike complaints, no hard evidence of change or benefit is required by consumers to
drive engagement, but motivation to engage must be credible as well as persuasive
Organisation
Compensation/reward
Altruism - helping others
Develops customer/supplier
relationship
Key Drivers- Belief that feedback will have
impact is important
Help shape future experiences
Encourage/discourage use
That’s what you hope isn’t
it? If you’re giving
feedback there’s going to
be a reaction: something’s
going to happen
(G4: non-commenters 40+ y/o)

Definition of and attitudes to feedback were
similar across both occasional commenters
and non-commenters
• Even non-commenters were familiar with requests for feedback
• Most non-commenters had experience of giving feedback at some
point (even if a letter or personal ‘thank you)
• Greatest differences seen across age groups
• Younger non-commenters would provide feedback in principle – just
lacked motivation
• Over 60s in general were less inclined to participate in feedback
• 60+ Commenters had generally done so by letter/phone to complain,
say ‘thank you’ or had provided feedback when prompted

Feedback on NHS Services

NHS customers have some difficulty in
understanding drivers for feedback in the context of
NHS services
What will be achieved?
Who will benefit?
Change in service
Change in behaviour
Self
All users/customers
Low belief in being able to influence change within the NHS is a major barrier to
engaging in feedback with NHS services
Organisation
Best achieved via personal
complaint/thank you not feedback
‘An ideal’ but doubt relevance of
personal experience to wider NHS
community
Doubt that NHS organisation will be able
to effect change based on feedback
Key Drivers
Customers currently feel influencing
change is beyond their control
Low awareness and credibility of choice
within NHS services
Your relationship with the
NHS isn’t a purchasing
relationship; it’s not about
spending money, it’s
about being treated
(G2: non-commenters ≤40 y/o)

So… Feedback, as understood by the general
public, does not currently fit naturally within
the NHS space
•Not a commercial customer/supplier transaction
•Most experiences of NHS services are both personal
and emotional
•Low expectation that feedback will result in changes to
services
•Awareness and belief in ‘consumer choice’ within NHS
services is low
NHS customers doubt credibility of ‘end benefits. Neither assisting others with
consumer choices nor driving improvements are currently seen as achievable
outcomes
• Who will be interested?
• What will it achieve?
It’s a bit different with the
NHS because you can’t
pick a hospital
(G2: non-commenters ≤ 40 y/o)
For a service where I
know the people
personally then I would
rather say thank you
personally

NHS customers’ affection for the NHS means
they don’t want to give negative feedback
• Far more leeway allowed for delays and inconvenience than in
commercial customer/supplier relationships
• Concern that any criticism will impact on their future use of NHS
services
• Communication with the NHS services is generally triggered by a
serious ‘complaint’ requiring action and a satisfactory resolution
• Response is personal and directed
• Older NHS customers, in particular, do not yet understand the
value of ‘constructive criticism’ in the context of shaping
improvements in ‘their NHS’
NHS service users require educating of the benefits of ‘constructive criticism’. There is
low acceptance that by sharing experiences they have the power to shape the future of
‘their NHS’
I couldn’t go and
complain to my
doctor… there’d be
this friction between
us
(G3:commenters 40+ y/o)

Customers are happy to give positive feedback but
want it to reach the people responsible
• Low levels of expectation of NHS services (mainly hospital and
GPs) means that when services go well it is ‘as it should be’
• ‘Customer delight’ when services far exceed expectations is
generally rewarded in person to the individual provider
• Older NHS users, in particular, recognise the power of a ‘thank
you’ but are the most likely to reward providers either verbally or
with a small gift
• But recent potential closure of local services has motivated some
(younger) customers to add their support on-line – a wish ‘to be
counted’ among other supporters
The general public retains a strong affinity to ‘their NHS’ and are prepared to say ‘thank you’
at a personal, local level. Customers need to be persuaded that sharing their positive
experiences more widely can benefit the broader community of NHS users
I just wanted to give a
little support to them
because obviously
they are facing
difficulties at the
moment

Email/letter Telephone
DiscussionFormal
Social Media
Like
Website
Share
‘Feedback’ channels are not those where
communication with the NHS will usually be carried
out
• After discussion, most respondents could be persuaded of possible benefits of
giving feedback on NHS services – but younger NHS users, particularly, feel on-
line is the most appropriate channel
• Response from many older NHS users (60+) shows many will prefer telephone,
contact, but this group requires greatest education about being involved in
patient feedback and therefore less likely to use unprompted
I kind of realised this is
[call operator] transcribing
what I’m saying to go on a
website, whereas I could
have just done that myself
Feedback
(one way communication)
Communication with NHS
(two way communication)
Communication
style

Evaluation of the Telephone
Feedback Line

There is no perceived requirement for a
telephone feedback line by NHS customers
• But the opportunity to contact the NHS
via telephone has strong appeal to the
less internet savvy
• Older customers in particular welcome
the chance to complete the transaction
via telephone and will use the service if
provided
A ‘feedback’ line will need clear routing/signposting to ensure that it does not
become an entrance point for a wide range of queries and complaints
I like immediate contact.
The human voice, or
preferably face-to-face,
rather than something that
is happening out in cyber
space

Though introducing a telephone option generated
many calls, only a minority was genuine ‘feedback’
• Used principally as another means to register
complaints or clarify issues with the NHS Choices site
• Only customers calling to leave feedback were
referred onwards to participate in our research
• None of the focus group participants would have used
the feedback line without being tasked to do so
• A small minority said they would consider using the
telephone feedback line again in the future
• But a majority projected they would ‘cut out the middle
man’ and leave any feedback on-line
The telephone feedback line is likely to prompt reverse channel shift. Much of additional feedback
generated (ie would not consider on-line) is more likely to be from (older) NHS users that require
most convincing of the benefits of providing feedback
Call Type No. %
Feedback 41 20% 31 respondents to survey (76%)
Complaints 26 13%
Other 139 67% • Examples:
• enquires about hospital
appointments and test results
• wanted to find out their NHS
number
• unable to access Choose and Book
• GP surgeries/ dentist new
registrations…
Call breakdown as at beginning of fieldwork

Benefits of telephone communication…
 Personalises the service – a ‘human touch’
 Reassured they are being ‘listened to’ – a two way
conversation
 Feel issues are owned and therefore may go further
 Someone to hear and react to points caller wishes to share
 An opportunity to ‘rant’ to a sympathetic ear
I didn’t want to
complain. It was more
of an opportunity to
have a bit of a rant
I think, to be honest, if you’re doing it
on the phone, you’re probably just
ranting. You want to get it out of your
system and you think ‘I want to talk to
someone’
(G4: non-commenters 40+ ( y/o)
After using the feedback line, NHS users can see a role for the service

Experience of using the Telephone Feedback
Line was overall strongly positive
 All call handlers were attentive, sympathetic and
cooperative
 Experience was a long way from mass market, high
volume call centres users feared
 Staff were not expected to be medical ‘experts’ but
handled calls intelligently and flexibly
 Re-checking comments given at the end of the call
provided reassurance that users had been listened to
and would be accurately represented.
Highlights…
 Most calls answered in a couple of
rings
 Process clear and simple to use
 Left users feeling happy after positive
feedback and ‘unburdened’ after
negative feedback
 2 respondents felt comments could
contribute to saving local services
If you’re talking to a
human being,
someone’s literally
listening to you
I just feel if you speak
to a person you feel
as if your comment
will go somewhere
rather than just to a
space
(Female 40+)

However, there are areas to improve …
 At busy times phones were not answered quickly
 Request for personal details causes suspicion
 Demand for ethnicity, age and phone number sits poorly
with anonymity promised
 Delays experienced due to inability to find target
hospital/practice (calls lasted up to 45 mins)
 Customers are unlikely to know services by postcode
 Process not flexible enough to deal with comments
involving several sites
 Some frustration at inability to ‘name names’ in feedback -
especially when wanting to say ‘thank you’
 Call centre operators may benefit from specific training to
manage search process
I was a bit disappointed [not
being able to give names]. I
thought it was a waste of time
I would have had to make 7 or 8
statements for various people in
various departments in various
hospitals because she had no
‘catch all’ box
(Female, 40+)
I would have preferred to use
the website – it would be
much quicker
(G2: non-commenters ≤ 40 y/o)
I did actually think ‘I hope she’s
like spelling everything
correctly!’

Specific points to focus improvements …
Eliminate requirement for demographic details up front and
explain reasons for collection
Explain request for a contact telephone number
Minimise delays caused by address searches
Ensure provider details and addresses are up to date
Eliminate mobile call charges: 14p/minute
Provide a facility to attribute comments across several services
and locations if required
Ensure call handlers are trained to deal with handling
complicated spellings and medical conditions to avoid awkward
questions

There is no expectation that feedback
requires a personal response
• Only complaints require acknowledgement and
reassurance the matter will be responded to
• Feedback is viewed as ‘one way traffic’
• Commenters expect that their comments will
appear on site (but have no strong feelings
about it)
• They assume their comments will ‘filter
through’ to the wider NHS community
• A ‘thank you for your feedback’ at the end of
the process would be a nice touch
• NB respondents were not
current users of the NHS
Choices Website
• Although many post-
interview said they would
look in the future
If the purpose of the feedback is for
people to look at the website and read
reviews, if you like, I’m not sure how
valuable that is for somebody like me.
But if it’s to get the information to the
right people and to improve services –
just to say ‘Well done. We all like this…’
then I’m behind that. Absolutely
(G3: commenters 40+ y/o)

Communicating NHS
Telephone Feedback line

Choice of name / description of the feedback line
has a strong impact on service expectations
• Customer Service Line has negative associations for
many
• Low service expectations
• Staff expected to be poorly trained
• Commercial: Banks, telephones, utilities
• Unlikely to end in a satisfactory resolution
• Suggests a ‘two way’ service. Feedback = 1 way
• 111 service was recognised by a minority of Merton
respondents and could include a feedback line
• Would need to be clearly routed
• Purpose of broader 111 service unclear at this stage
• ‘Feedback’ clearly defines the purpose of the line
• Although still faces issues about providing feedback on NHS
services
111 sounds too much of an
important number for a
feedback line!
(G2: non- commenters ≤ 40 y/o)
From my experience of
customer service you expect
nothing and you really get
nothing

NHS users believe the feedback line should
be publicised at point of service
•Service users are in a ‘patient’ mindset
•Time to read and absorb communications
•Posters and leaflets in waiting rooms or
messages on appointment cards would be
appropriate
•Should be promoted locally to emphasise
local services will benefit
•NHS users are realistic enough to assume that
a large scale TV campaign is unlikely to be
funded by the NHS!
Given most feedback is anticipated to be on local services, NHS users believe they should be
encouraged to become involved also at a local level - an opportunity to influence community
services that they or their families use

•An emotional appeal to the affection felt for the NHS will
resonate strongly
•Motivation to participate should be altruism rather than reward
(distances ‘feedback’ from ‘complaints’)
•NHS users buy into the idea of health services that (should)
provide a positive experience for all
•They are open to persuasion that by providing feedback they
are playing their part
•Communications should offer motivating end benefits that are
credible and achievable
•Language used to describe the NHS/user relationship must
avoid suggesting a commercial customer/supplier relationship
•‘customer’ is strongly disliked: ‘patient’ preferred
•‘listen’ and ‘hear’ reassure that comments will go further
•‘comment’ ‘review’ and ‘feedback’ all carry different
expectations
Key message should put the focus on
actively helping ‘your NHS’
Your relationship with the NHS isn’t a
purchasing relationship. It’s not about
spending money it’s about being treated
(G2: non-commenters ≤40 y/o)
It might make you feel civic
minded or helping your
community
(G1: commenters ≤40 y/o)
People need to understand
what it’s for and if it is to
make the NHS better

Next Steps

Moving forward, customer insight would
recommend …
 Clearly position the telephone line as a ‘feedback line – emphasise the importance of
‘reviewing’ and ‘sharing’ to differentiate it from complaints
 Target, primarily, older NHS (60+) users that would prefer a human voice to ‘guide
them through the feedback process’: younger users can be directed on-line
 Offer those that engage in feedback credible and achievable benefits for participating
in service feedback: an opportunity to influence change
 Educate NHS users about choice within the NHS to motivate them to share their
experiences with the wider NHS community: emphasise ‘constructive criticism’ is as
valuable as positive feedback
 Ensure the telephone feedback process is not prolonged unnecessarily (hindered by
address searches or spelling out conditions or procedures). The focus should be on
feedback content not classification facilitated by well trained staff
 Publicise the telephone line as ‘helping your NHS’ a means of sharing personal
experiences with the local community to help shape the future of their local services

Questions and comments to:
thechoicesteam@nhschoices.nhs.uk please quote “Slideshare” in subject
line

Patient Feedback Line Pilot Provides Valuable Insights

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