This year, on its 50th anniversary, Britain's National Health Service is asking patients what they think about the care it gives. It has called on the Yanks to help.
The Picker Institute of Boston, a well-known collector and analyzer of patient opinion data in the U.S., recently won a $20.4 million, six-year contract to survey NHS patients in England.
Picker staffers say the project is the largest, most aggressive of its kind anywhere. It attempts to elicit a comprehensive portrait of one of the world's largest centralized healthcare systems, serving 55 million people.
Picker will initially survey 220,000 NHS patients receiving primary, cancer or cardiac care. It will later add mental health, pediatrics and obstetrics.
"The goal is not to tell England how people are doing, but to tell hospital by hospital and practice by practice how they can improve," says Tom Delbanco, M.D., chairman of the Picker board.
The project is being carried out by Picker Europe, a joint venture of Picker and Swedish-based BURE Health Care.
Prime Minister Tony Blair's administration has made improving the NHS a priority as the system undergoes wrenching reform, which will hold groups of physicians accountable for defined patient populations.
"Nearly every organization that's got any sense tries to find out what the people it's responsible for think of the service that's been provided," British Health Secretary Frank Dobson told BBC Radio earlier this year.
Despite the public's high esteem for the NHS, many patients are deeply frustrated, particularly with long wait times for appointments and procedures.
An earlier Picker survey, at 36 NHS hospitals between October 1992 and June 1993, found widespread deviations in standards of care. For example, 56% of patients found communication with staff unsatisfactory, and 70% had not been told what to watch for after discharge.
"(In North America), if we get a problem score over 30%, that's pretty bad. In the U.K., there were certain dimensions of care we look at in our surveys where we were getting 50% problem scores," says Susan Edgman-Levitan, Picker's president.
"In some ways they are where we were in the 1950s. . . . It's not unheard of in Britain for a doctor not to tell a patient they have a serious illness," she says.
In 1992, the British Department of Health, which oversees the NHS, published The Patient's Charter, which encouraged patients to complain and led the government to consider incorporating patient views into a continuous quality-monitoring process. Picker worked with hospitals on improving service, which laid the groundwork for the new survey, Edgman-Levitan says.
Under the imminent reform, groups of 50 primary-care physicians, called trusts, will receive capitated payments to purchase hospital and specialty care for their patient panels. Each trust will undergo an annual quality audit, including patient satisfaction.
The British Medical Association, which represents doctors, says it welcomes the effort to solicit patient views but is concerned about the methods. For example, a draft survey asked whether a physician "knew enough about your condition or treatment"-something a patient couldn't be expected to know.
The questionnaire is also quite long, which could bias the results by creating "questionnaire fatigue," a BMA spokeswoman says. "Toward the end, you don't get the same response."
Key findings are scheduled to be published next spring, followed by a detailed report. But that timeline could be delayed by the approval process. Stephen Bruster, who is designing the surveys for Picker in London, says that before the questionnaires can be mailed, they must be approved by the national Multi-site Research Ethics Committee, then by a local ethics committee in each jurisdiction.
The national committee has raised questions primarily about confidentiality and copyright. As of early last month, only one of the surveys for primary care had been approved.
If the Picker project proceeds as planned, it will catapult England to the front of the pack of those using patients' experience to improve healthcare quality.
Picker, founded in 1987 and spun off in 1994 by the Commonwealth Fund, a large New York-based healthcare philanthropy, has surveyed more than 200,000 healthcare consumers at more than 500 hospitals, medical groups, health plans and other healthcare institutions, according to its World Wide Web site.
Picker launched international surveys of Canadian and British patients in 1991 and more recently has been working on projects in Germany, Sweden and Switzerland.
Ian Stevenson, a vice president in charge of finance at Picker Boston, says, "We have learned in our work, a patient in pain in Leipzig is not all that different from a patient in pain in London or Los Angeles."