Are you satisfied with your doctor?

On a regular basis I receive a letter from the NHS. It's a survey which asks me to complete several questions about how satisfied I am with my GP. Invariably, the letter goes straight to the bin. And here is why.

The NHS have conducted patient satisfaction surveys for several years now (done by CQC) and they are beloved by politicians of all colour. Whenever the discussion turns to productivity or care outcomes in the NHS,  politicians are quick to point out that patient satisfaction is at an all time high in the NHS (it currently is about 96%). Somehow patient satisfaction rates are meant to counter any criticism of the NHS. I believe this is a spurious argument and one that does not stand up to scrutiny.

There are clearly some things surveys can find out. They fall into the category of 'facts' such as how many times somebody has visited their doctor recently and the like. Although patient surveys are actually not the best way to establish good data on these things, I can see that you may want to ask them in a survey with some justification. I still think responses to these questions should still be treated with caution given that we are all human beings and our memories play tricks on us with even more mundane issues such as remembering whether it was raining yesterday or where we put our car keys.

Be that as it may, the real problems emerge when it comes to the responses these surveys are really after: patient satisfaction. A typical question of this sort runs like this (this is an actual question from the regular GP survey I receive): 'How would you describe your experience of your GP surgery'? 'Very good, fairly good, neither good nor poor, fairly poor or very poor.

Well, let me think about this... First of all, I am not sure what this question refers to. Do they ask me to rate the pictures hung up on the surgery walls? Or are they after my opinion about the doctor's willingness to give me the drugs I want?

Yet, it is not only the fuzziness of the question that makes this survey an exercise in futility. More importantly, how would I know what is a 'fair, good or poor' experience? I tend not to visit my GP and then pop to another one down the road to see if she is any better. The nature of the healthcare experience is that it is rarely comparable. I have not heard of a single person who had a liver transplant at a London hospital and then, for the purpose of gaining comparative expertise, drove to Newcastle to test the local surgeon's skills by asking them to perform a similar operation.

Since the medical experience is most likely to be unique for most people, personal opinions of what constitutes a 'good' or 'poor' service are likely to be indiscriminately hovering in the 'satisfied' range, with only those patients blipping on the radar who have, for one or another reason, been seriously disgruntled about the service they received. Those are most likely to have encountered problems with their care which often end up at tribunals or on the desk of a solicitor. So, no surprise then that NHS surveys regularly indicate a high satisfaction rate of patients. We wouldn't know better! That's why the survey letter from my GP always goes straight to the bin. I happily profess my ignorance!

Why we don't criticise the NHS

A recent survey showed that people are reluctant to criticise the care they receive by the NHS. Whilst we are happy to rate pretty much any service or good we obtain, from mobile phones to hotel stays, we are far less likely to say something critical about the NHS. The Guardian has reported on the result of this survey and the figures are revealing. Only about 250 people go online every day to rate their experience with the NHS, out of 1 million daily encounters in the NHS between care staff and patients.

The authors of the report suspect reverence for medical professionals the main reason. But another reason for why we rarely say much about the NHS is that we simply don't know. Look at it this way.

Rating a good or a service inevitably involves comparing it to a previous experience. We may often not be aware of this comparative exercise, but when we say something about a movie we have seen, we intuitively judge it against a previous movie experience. Although comparisons are complex mental exercises, the fundamental component of any comparison is a previous experience of something that we deemed sufficiently similar to compare it to. That may be easy with movies, yet harder to come by when we think about a colonoscopy. Experiences of medical care are mainly non-comparable, singular events in their nature. We do not have an operation to remove our appendix at Central Manchester Hospital and then decide to go to France to have the same procedure all over again. Once it's done, it's gone.

Not your usual NHS staff - or so you hope!

That illustrates of how little use NHS satisfaction surveys are. People simply have nothing to compare it with when it comes to medical care experiences. At best, they may re-visit the same hospital again and their rating may simply reflect whether or not the hospital itself has improved its care quality over time. Cross comparisons between hospitals or even between the NHS and other care organisations can hardly be based on patient satisfaction surveys.

As a foreigner, I have the privilege ( or perhaps the misfortune) to know two health systems, the NHS and the German system, a de-centralised health care model based on mixed economy health providers. I also work in a university hospital in Wales, one of the largest in the country. Although I bristle at the dire state of hygiene in NHS hospitals and the poor food, I could hardly comment on whether Welsh surgeons would do a better job at operating my appendix than any German doctor would. What I do know however is that if I hear any politician speak of how great the NHS is because they have the highest satisfaction ratings in years, I will roll my eyes and hope I never be asked to fill in one of those surveys.