Measuring patient experience in NHS Dentistry

A consistent criticism of NHS dentistry has been the continued focus on treatment and activity rather than prevention and oral health outcome; a pre-occupation with “quantity over quality.” Jimmy Steele acknowledged this in his 2009 report and highlighted the need to design a contract which provides “much clearer incentives for improving health, improving access and improving quality.”¹

We would all agree that dental care professionals should provide care of a sufficiently high quality for our patients, and it would not be unreasonable to expect to work within a system that supports this. Sadly, it is generally accepted that the current NHS contract does little to incentivise or reward high quality care, and I guess we should be encouraged by the fact that the contract reforms appear to be addressing this by developing a Dental Quality Outcomes Framework (DQOF).

The DQOF was initially based on three dimensions of quality as recommended by Darzi²: Clinical Effectiveness, Safety and Patient Experience. This has subsequently been refined with the introduction of two additional domains (Best Practice and Data Quality) within the prototype contracts. The addition of a domain which rewards dentists for submitting NHS claims on time perhaps gives some insight into the level of confusion which exists around the concepts of quality management and performance management. Submission of claims on time is certainly important for the smooth running of the system, but it is difficult to comprehend how this is related to the quality of patient care.

The Dental Quality and Outcomes Framework (DQOF)

This lack of understanding about quality in dentistry is further highlighted by the current design of the “patient experience” domain within the DQOF. Patient experience is recognised as a key component of assessing quality within the NHS, and the current DQOF includes seven questions purportedly related to experience. At first glance these questions may appear relevant “How satisfied are you with the NHS dentistry received?” or “Would you recommend this practice to a friend?” or “How satisfied were you with the cleanliness of the practice?”

They all seem quite reasonable questions, but do they provide an accurate assessment of patient experience?

You would certainly hope so, as the current intention is to assign 10% of your GDS contract to DQOF, and a failure to hit your target will result in financial penalty. When the QOF for GPs was introduced in 2004, significant investment was made to incentivise improvements in quality with a 25 – 30% increase in practice funding. Unsurprisingly, the situation is very different in 2015 for dentists. There will be no additional funding and no financial incentives – only financial penalties if we don’t hit our targets. They get the carrot, we get the stick!

When we look more closely at the questions within the “patient experience” domain it becomes apparent that the focus is primarily on patient satisfaction. This would seem strange as the NHS Patient Experience Framework actually states that “measures of satisfaction have a commonsense and political appeal, but they are the measures that experts, including experts in quality improvement, consider the least useful”.³

This all might seem a bit academic, and in practical terms not that relevant. Surely if you provide a good patient experience you will end up with a high level of satisfaction? This is possibly true, but definitely not the whole story.

Patient satisfaction surveys are widely used within healthcare and are a very useful way to obtain feedback and improve services at a local level. Dental practices regularly use patient satisfaction surveys to understand what their own patients want and respond accordingly. It is a fundamental strategy in developing and maintaining a successful dental practice. However, there is a subtle difference in using patient satisfaction to improve services and attempting to use the same approach to measure quality across a wide range of providers.

Patient satisfaction has been developed from consumer marketing and is based on disconfirmation theory where the quality of the service is measured against the expectations of the individual. The level of satisfaction expressed can therefore be as much about the patient’s expectations as it can about the quality of the service provided.

This can perhaps be best illustrated by the example of two colleagues, let’s call them Eddie and Mick, who decide to go out for dinner at two separate eateries. Eddie decides to go to a Michelin star restaurant; Mick chooses McDonalds.

Eddie’s restaurant is very exclusive, with attentive staff and lovely surroundings. Unfortunately, Eddie has a bit of a weak stomach and he doesn’t particularly enjoy his grilled octopus. On completing his customer satisfaction form, Eddie considers himself to be “satisfied”, despite the disappointment of his main course.

Mick has fairly low expectations, but is pleasantly surprised with his ‘happy meal’ and the unlimited access to free ketchup. He is even more impressed when he receives a complimentary toy, which just happens to be ‘Olaf’, his favourite character from Frozen. On completing his customer satisfaction form, Mick considers himself to be “very satisfied”.

In analysing this data, one could conclude that both ‘customers’ were satisfied, although Mick was more satisfied than Eddie. We might therefore assume that the quality of the experience provided at McDonalds was superior to that of the restaurant. This may of course be entirely inaccurate, and could simply be an indication of the varying expectations of the two individuals.

I would not wish to repeat the same mistake as our beleaguered Chair of the GDC, by comparing dentistry to supermarkets, but hopefully this example might illustrate the dangers of using patient satisfaction as a measure of quality. In our world, the same situation applies where patients rate services based on their expectations and not on the quality of care provided. We all work in very different practices, in different communities with patients who have different backgrounds and very different expectations. It would therefore be inappropriate to use a measure of quality for dentistry based on patient satisfaction alone.   

There is extensive literature on measuring patient experience, which is closely aligned to the dimensions of “patient-centred care”. Various tools have been developed and validated, and it is disappointing, although perhaps not surprising, that NHS England have chosen to design their own non-evidenced approach. To be fair to NHS England, they have stated that they are developing new Patient Reported Experience Measures (PREMs) which they intend to validate before introducing them⁴. A refreshingly robust approach when compared to the imminent introduction of the Friends and Family Test.

Image credit -  Chance Projects  under CC licence - not modified.