Implementation and use of the Friends and Family Test as a tool for local service improvement in NHS general practice in England

Between 2013 and 2015 the Friends and Family Test (FFT) was rolled out across parts of the NHS. It consists of a single question asking whether the patient would recommend the service they just received to their friends and family. Answers are recorded on a 5-point scale from “extremely likely” to “extremely unlikely”. This is followed by an open-ended question asking why the patient gave the particular response. Although originally intended to support patients in choosing the “best performing” services, the guidance from NHS England (NHSE) was subsequently modified to say that feedback from the FFT, in particular from the open-ended responses, should be used to identify and address quality issues.

The Department of Health and Social Care commissioned PIRU to investigate whether and how the Friends and Family Test (FFT) contributes to the improvement of services in general practice. Our study aimed to investigate how the FFT was implemented in general practice, and whether the data generated were used by local staff to improve the quality of services provided.

We carried out semi-structured qualitative interviews with staff from a purposively selected sample of 42 general practices distributed throughout four NHS regions in England. We also interviewed staff from the four related NHSE regional teams, as well as from two innovative general practice organisations and from the Royal College of General Practitioners.

Within each practice, the target was to complete three interviews: one with a clinician, one with the practice manager (or another administrator) and one with a representative of the practice’s Patient Participation Group. One hundred and thirty-four individuals were interviewed in October and November 2015. 

Practice staff found the Friends and Family Test (FFT) to be easy to implement and to require few additional resources. Nonetheless, practices were not very engaged with the FFT and rarely did more than the minimum required contractually. The purposes of collecting the FFT were often unclear to staff, with many believing that the FFT was intended for performance management, leading to a general lack of local “ownership” of data collection. The FFT was perceived by the majority of staff as a process carried out locally on behalf of DH/NHSE. 

FFT quantitative data were considered to lack accuracy as the patients who responded were few in number and generally self-selected, thus producing a biased sample. Moreover, the reference to a “recommendation” in the FFT question was deemed by most interviewees to be inappropriate for general practice because the relationship between practice staff and patients is personal and complex. The free text comments were considered by staff to lack sufficient detail to identify quality of care issues in a way that would enable them to be addressed. 

Positive effects of the FFT on staff morale were reported, but several interviewees were frustrated that they could not act on the negative feedback that patients sometimes provided since it was generally anonymous. Overall, the impact of the FFT on quality improvement was negligible and other tools (such as practice surveys and Patient Participation Groups) were said to provide better patient feedback and be more helpful for quality improvement. 

If a single item instrument, such as the FFT, is to be used to stimulate quality improvement in general practice, then its impact could be improved in five ways by:  

1. Enhancing the general capacity for managing quality in practices;  

2. Changing the content of the FFT; 

3. Modifying the method of data collection; 

4. Improving practice staff understanding of the purpose of FFT;  

5. Altering the national reporting requirements.