Candid 'insider' views on quality, safety in NHS could help detect reasons for poor care, say researchers

This finding by researchers in the Universities of Leicester, Aberdeen, and Bristol has been published in a paper, 'The friends and family test: a qualitative study of concerns that influence the willingness of English National Health Service staff to recommend their organization', in the Journal of the Royal Society of Medicine.

Since 2009, the annual Staff Survey across the NHS in England has asked staff to say whether they agreed with the statement that: 'If a friend or relative needed treatment I would be happy with the standard of care provided by the organization'. On average, around two thirds of staff agreed with this statement in 2013, but the lowest score was 39.5% and the highest was 94%. Despite this variability, it was not known why staff appear to be more willing to recommend some organizations more than others.

Professor Mary Dixon-Woods, Professor of Medical Sociology at the University of Leicester, says: "The hard data that shows that, overall, NHS staff are supportive of the care provided by their organizations. But that's not consistently the case always and everywhere. What was missing was 'softer' intelligence to help us to know what lies behind the scores and what to do in response.

"We aimed to identify what explains staff's willingness to recommend their organization. We undertook 168 interviews with people across the NHS that included the question: 'If a friend or relative were treated in your organization, what would concern you most?'"

Staff offered detailed and candid responses to this question, with some saying they had no concerns and others having multiple concerns. Most said that they could identify good features of their organization but it was reliability that concerned them most.

Many of the issues were revealed to be deeply structural, and related to problems such as poorly designed and badly functioning systems; under-staffing, including lack of availability of the right skills; and under-resourcing due to competing priorities.

There were concerns about clinical care, including incorrect diagnoses, inappropriate therapies and poorly administered interventions; lack of management skills; and some unprofessional conduct. Interviewees felt that many problems with caring arose when staff were harassed and over-stretched by too many competing demands and priorities, or when they lacked effective leadership.

Professor Dixon-Woods says: "Sir Robert Francis, in his recommendations about how to address quality of care in the NHS, said that feedback from staff should not only be encouraged but insisted upon. This study shows that asking staff directly about what concerns them can yield much valuable intelligence about where improvements can be made. The next stage will be to see if this can be reproduced outside a research context. That means providing opportunities for staff to speak up not just about incidents and major concerns, but about the little things that get in the way of providing good care too. And it means ensuring that it is safe for staff to raise those concerns and that action is taken in response."