Dr Honor Merriman offers top tips about making the most out of feedback from patients and colleagues

Honor Merriman

Dr Honor Merriman

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Read this article to learn more about:

  • tips and tools for gathering feedback for revalidation
  • how feedback should be explored during appraisals
  • using feedback constructively to develop and improve.

In 2018, Sir Keith Pearson, then-Chair of Health Education England, said: ‘In my experience, doctors are keen to know how they are perceived by their patients and patients are keen to have their voice heard. There is a growing understanding in health systems across the world that patient feedback has huge potential to help doctors better understand their practice and improve their professional attitudes, skills and effectiveness.’1

Feedback can be derived from many sources: colleagues, informal feedback in the form of thank-you letters, informal and formal complaints, the NHS Friends and Family Test,2 and even information about the GP practice ‘overheard in Waitrose’. Many GPs fear feedback because a lot of it is negative (patients expect an excellent service so only speak up when it is not). In fact, many surveys reveal that GPs are highly regarded as individuals,3 but the NHS itself has poor feedback.4

This article is written from a GP appraisal and revalidation viewpoint where formal feedback is generally only sought every 5 years. However, the process of learning from feedback should be a regular (even daily) process in every GP’s development.

1. Consider online tools to collect patient feedback

The General Medical Council (GMC) does not recommend any specific appraisal website; however, websites such as Clarity6 and FourteenFish7 offer suitable surveys that can be incorporated into an appraisal portfolio. Both also provide paper surveys, and FourteenFish offers a variety of surveys to suit GPs in different roles. These can be downloaded by the GP, then handed out by a receptionist. Once handed back in, the completed surveys can be scanned and sent back to FourteenFish. Clarity also offers an email patient survey. The choice of whether to do a patient survey by email or on paper should belong to the patient, not the GP, and Clarity allows submission of both email and paper information to capture patient preference. When analysed on a website, the scores are benchmarked against national and area team results. For several questions, patients score most GPs as good or very good both locally and nationally.

Free text comments can also be helpful for pinpointing areas of good practice or areas where performance can be improved.

There are several other websites that also collate patient feedback. If your appraiser has not heard of one, it is expected that they will check the validity of the site with their appraisal lead or responsible officer (RO).

Regardless of how you choose to survey people, it is always important to bear in mind the GMC requirements for survey feedback (see Box 1). If you do not believe you can collect relevant information, you will need to agree this with your RO.

Patient surveys in the time of COVID-19

In order to ensure that a representative sample of patients give feedback, paper surveys have been advised in the past in many areas. Older patients and those who do not use email are thus able to give feedback on a GP they have seen. In the last 6 months, fewer patients are seen face to face and passing paper documents in practice reception areas now poses an infection risk. Online patient questionnaires now seem more sensible and, as long as they are independently administered (to avoid patient selection by the GP) and collated, should be used.

Box 1: GMC requirements for feedback from patients or those to whom you provide medical services5

  • At least once in each revalidation cycle you must collect, reflect on and discuss feedback from patients about their experience of you as their doctor
  • If you do not have patients you should collect feedback from others to whom you provide medical services. If you believe you can’t collect such feedback, then you must agree with your responsible officer that you do not need to
  • Those asked to give you feedback must be chosen from across your whole scope of practice
  • You should use standard questionnaires that have been validated and are independently administered to maintain objectivity and anonymity. You must agree any alternative approaches with your responsible officer
  • You should not personally select those asked to give feedback about you, and you should make sure the method used for collecting feedback allows responses to be obtained from a representative sample
  • You must reflect on what the feedback means for your current and future practice, and discuss it at your appraisal.

© 2018 General Medical Council.

General Medical Council. Guidance on supporting information for appraisal and revalidation. GMC, 2018. Available at: www.gmc-uk.org/-/media/documents/rt—supporting-information-for-appraisal-and-revalidation—dc5485_pdf-55024594.pdf

2. Learn from both complaints and compliments

The GMC also expects healthcare professionals to declare and reflect on all formal complaints (see Box 2). Having a complaint made against you is always painful. Sometimes, nothing could have been done any differently and the patient is assuaging their feelings about an unsatisfactory situation by attributing blame to the GP. Other cases are due to a simple misunderstanding that can often be resolved by a phone call and a letter. It is good practice to acknowledge the complaint quickly and work with colleagues to investigate the complaint. The response to the complaint includes your findings and therefore demonstrates that you have gathered all the relevant information before responding. Adding comments to show what will be done differently in the future, by you or other members of your team, can reassure patients that their complaint will improve things for the future. Sometimes a complaint leads to behaviour change in a GP, and in practice a whole system is led to improve. Talking about a complaint during an appraisal discussion can allow the development of thoughts about future change in a supportive setting.

You may not have been personally named, or involved, in any complaints during the year, in which case you may wish to declare as much to your appraiser. You can still reflect on other relevant feedback that contributed to changes in your practice, or reinforced existing good practice.5

Box 2: GMC requirements on compliments and complaints5

  • You must declare and reflect on all formal complaints made about you at your appraisal for revalidation. You should also reflect upon any complaints you receive outside of formal complaints procedures, where these provide useful learning
  • You do not have to discuss every complaint at your appraisal. You should select those that evidence your insight and learning into your practice, and those that have caused you to make a change to your practice. You must be able to explain to your appraiser, if asked, why you have chosen these complaints over others as part of your appraisal discussion
  • At your appraisal, you should discuss your insight and learning from the complaints, and demonstrate how you have reflected on your practice and what changes you have made or intend to make
  • You should follow the same principles for collecting, discussing and reflecting on compliments.

© 2018 General Medical Council.

General Medical Council. Guidance on supporting information for appraisal and revalidation. GMC, 2018. Available at: www.gmc-uk.org/-/media/documents/rt—supporting-information-for-appraisal-and-revalidation—dc5485_pdf-55024594.pdf

3. Record informal feedback as it can still be valuable

Informal complaints may be painful but are often easily resolved by further explanation (and an apology) from the GP. Patients who make in-house complaints often seek resolution and they value a meeting and discussion. Misunderstandings cannot always be avoided, but sometimes the system in the practice needs to be changed and both the GP and the practice can learn from doing this. Similarly, significant events (now helpfully called ‘learning events’ by the GMC5) can be informative and lead to constructive change.

Comments left on social media do not usually help the practice to improve; however, if a practice has a presence on social media this can be a good place to signpost information about how to contact the practice directly and how to make a formal complaint if one is indicated.

‘Thank you’ letters and cards can be heart-warming and reinforce good practice. They can be scanned into an appraisal portfolio, provided that any patient identifiable information is removed. My recent favourite thank you was a personalised very large slab of chocolate, which I scanned into my portfolio—then ate!

Information from patient feedback can lead to simple solutions, such as reviewing the timing of appointments in GP surgery sessions, and allowing more time for catch-ups and telephone calls. Sometimes after the appraisal discussion the GP can decide to alter their work pattern or even the type of work they do. Developing new skills can open different areas of practice and doing different things can be energising.

4. Get honest and constructive feedback from colleagues

Websites used to gather patient feedback can also be useful for collecting feedback from colleagues, which is also essential for revalidation (see Box 3).

Box 3: The GMC’s requirements on colleague feedback5

  • At least once in your revalidation cycle you must collect, reflect on, and discuss at your annual appraisal, feedback from your colleagues
  • The colleagues who are asked to give feedback must be chosen from across your whole scope of practice, and must include people from a range of different roles who may not be doctors
  • You must choose colleagues impartially and be able to explain to your appraiser, if asked, why you have chosen the colleagues who have given your feedback
  • Wherever possible you should use standard questionnaires that have been validated and are independently administered to maintain objectivity and confidentiality. You must agree any alternative approaches with your responsible officer
  • You must reflect on what the feedback means for your current and future practice.

© 2018 General Medical Council.

General Medical Council. Guidance on supporting information for appraisal and revalidation. GMC, 2018. Available at: www.gmc-uk.org/-/media/documents/rt—supporting-information-for-appraisal-and-revalidation—dc5485_pdf-55024594.pdf

As a GP appraiser, I often look at the results of colleague surveys and the most common item that scores less well is time management. Are all these GPs poor at managing their time? Might it be that we set ourselves the unreasonable expectation of meeting the multiple needs brought to a GP consultation in only 10 minutes? In responding to this type of information, the answer may not lie in changing the GP themselves but in analysing the GP’s role. In practices where this personal feedback is addressed through a more system-wide response, both GPs and patients are happier. The Royal College of General Practitioners (RCGP) advises that in the near future, 15 minute appointments should be made routine—with more time allowed for patients who need it.8

GP appraisers can have a report from the Revalidation Management System sent to them by the appraisal lead or senior appraiser. These are based on questionnaires sent to GPs after appraisals are completed. This information is valuable since it can reinforce areas of strength and indicate areas where improvement may be needed.

5. Obtain feedback from more than just surveys

The GMC asks that surveys are done across the whole scope of practice.5 Different roles need different skills and attributes. It is important to tease out where the development needs lie, so that they can be addressed. None of us is perfect in all aspects of our roles.

The standard colleague surveys are clinically based, so other surveys will be needed for feedback on GP who are in roles that are not patient facing (such as leadership roles). For example, FourteenFish offers surveys specific to practice managers.7

Surveys are not the only way to get feedback. Significant (learning) events can enable great performance in a near miss to be celebrated, or suboptimal teamwork to be identified in an event where the outcome was poor. Reflections on these events, as well as on surveys, should be noted down; the process of crystallising these thoughts into print helps to develop them into ideas about what change might be needed and how any change might be effected.

Practices where staff make time to talk to each other are not only happier but help share good practice clinically. One-to-one chats between peers can change ideas and behaviours. We all need to make time for each other.

6. Do not be intimidated by seeking feedback

Revalidation recommendations to the GMC are often deferred because the patient survey and separate colleague survey (collected at least once every 5 years) have not been done properly, if at all. This is unfortunate as it is a simple task for GPs with only one role who have not had any major job change. It is understandable that we are all busy but the continual improvement that is fed by consistent feedback over time is vital for us to develop. Instead of thinking ‘one survey of each type every 5 years is too much’, perhaps we should be asking ourselves ‘how much more feedback can we seek?’ so that we can keep improving.

Honor Merriman

GP Appraisal Lead, Thames Valley

References

  1. Pearson K. Improving patient feedback for doctors. Royal College of Physicians, 2018. Available at: www.aomrc.org.uk/wp-content/uploads/2018/05/Improving-patient-feedback-for-doctors-FINAL-web-version-1.pdf
  2. NHS England. Friends and Family Test. www.england.nhs.uk/fft  (accessed 27 August 2020).
  3. Ipsos MORI. GP patient survey—surveys and reports. gp-patient.co.uk/surveysandreports (accessed 27 August 2020).
  4. The King’s Fund. Public satisfaction with the NHS and social care in 2018. The King’s Fund, 2019. Available at: www.kingsfund.org.uk/sites/default/files/2019-03/Public_satisfaction_with_NHS_social_care_in_2018.pdf
  5. General Medical Council. Guidance on supporting information for appraisal and revalidation. GMC, 2018. Available at: www.gmc-uk.org/-/media/documents/rt—supporting-information-for-appraisal-and-revalidation—dc5485_pdf-55024594.pdf
  6. Clarity Informatics. Features for appraisees. Available at:  clarity.co.uk/wp-content/uploads/2019/10/Doctors-Appraisees.pdf
  7. FourteenFish. Info for all GP trainees and trainers. www.fourteenfish.com/ (accessed 27 August 2020).
  8. Royal College of General Practitioners. Fit for the future: a vision for general practice. RCGP, 2019. Available at: www.rcgp.org.uk/-/media/Files/News/2019/RCGP-fit-for-the-future-report-may-2019.ashx?la=en