In my last post, I rashly challenged someone to show me online comments about care homes. I called and the internet answered, in the form the lovely Best Care Home,who show the best of care homes, by encouraging positive reviews about CQC 3star rated care homes. As Debbie says“it is about time we heard some positive news about [care homes]”.

This got me thinking… What is the advantageof having critical feedback about care homes? Or, rather, what is feedback for?At Patient Opinion we feel that our aim in healthcare is to facilitate changethrough getting just the right patient story to just the right person in theNHS. This change would not be possible if it wasn’t for the stories having acritical element. Increasingly, this is how public services are changing,through service users donating their experience, to make a difference foreveryone else. The patient is a becoming a co-creator of the service.

So, is there a difference for privatesector organisations like care homes? Both care homes and NHS hospitals areoften demonised by the media, both are plagued by funding issues, and choice isan issue for both. So… the difference? The care home sector is in constantbalance between care and money. The majority of care homes are privatecompanies, with reputations to manage. An understandable fear is that criticalpublic feedback will impact on negatively on their reputation, and then impacton the number of future residents. Maybe the difference isn’t so great then –as hospitals have a reputation to manage, and wish to attract patients.

Which leaves me wondering, what are theoptions for care homes, when faced with online feedback? The options are: sue anyonewho allows people to write critical comments, or choose to engage with theseconcerns online. It’s not an easy path to follow, but embracing thetransformative power of the web might allow care homes to discover a new placein the 21^st Century.

When a word moves from the realm of the geekerati into the mainstream media, it's often a sign that some kind of cultural shift is afoot.

And so it is this week, as Victor Keegan writes an interesting piece in Technology Guardian on "hyperlocal". And, satisfyingly, Patient Opinion gets a mention.

To be fair, although we do offer some kind of hyperlocal potential, I don't think we have yet delivered it sufficiently. Perhaps our new API and RSS feeds will help a bit (see blog post not quite yet written), although we'll need to find some lat/long data to make them properly useful.

But Keegan's piece prompted a different thought: so far, the emphasis of hyperlocal seems to be almost entirely on providing information, rather than supporting civic involvement or community action. Again not yet delivered, but very definitely on the Patient Opinion"to do" list, is something a bit more along these lines.

As always in times of crisis and upheaval, we must recall Marx: "Bloggers have only complained about the world, in various ways. The point is to change it."

I think this applies to hyperlocal too.

There's been a fairly vigorous reaction to health minister Ben Bradshaw's proposal to allow patients to rate and review their general practitioner on the web.

Reading the blogs and the newspapers, I'd say the vote is probably running 4 to 1 against, with many familiar - and valid - arguments on both sides. Yes, we want more openness, more accountability for apparently aloof professionals. No, we don't want medical decisionmaking to pander to all demands, a site that encourages manipulative behaviour, spurious statistics.

One of the strong themes running through the critical comments - from both doctors and patients - has been a strong resistance to the idea of patients being asked to act as customers. 'We don't want to read or write reviews, nor score our doctors,' say the patients. 'We just want our doctors to be good, and trust them.'

But is asking patients to behave as customers what Ben Bradshaw had in mind when he announced the policy? Well, yes, it seems to be. For example, the Guardian reported:

'I would never think of going on holiday without cross-referencing at least two guide books and using Trip Adviser,' said Bradshaw. 'We need to do something similar for the modern generation in healthcare.'

Fair enough - but, in 2009, isn't this starting to feel a little Web 1.0? Is the 'Choosing what to buy' metaphor the best we can do?

Web 2.0 (this isn't exactly news) offers much more - the chance to move from customer to community, from me to us, from buying something to building something, together. As Ivo Gormley's recent film Us Now makes clear.

Our resolution for 2009 is to find ways to use the web to move from feedback on the web to change in the real world.

The NHS is institutionally attuned to the big things – what’s coming down from the big beast in Whitehall or the latest missive from the Chief Executive. This stacks up into institutional agendas that focus on things like Should we be shutting the casualty unit? Do we need another Consultant surgeon? How are we going to implement the Darzi report?

And when that isn’t occupying the operational brain space then it’s all the middle range stuff – how do we reduce the number of expensive bank nurses? When is the next data return due? How do we implement the latest policy on C difficile?

But the experience of the patient is made up of the micro – Was I washed gently? Did I feel included in my care? Was the place clean? Was it too noisy to sleep at night? Such things are visible to professionals who hopefully care a lot about getting them right, but they are more or less invisible to the institution except when they result in a complaint.

Patient Opinion takes thousands of these comments about micro aspects of care and makes them more visible. But what happens then? Well often not a lot. Being focused on the strategic or the middle-range must-do’s means that busy staff all too often see patient feedback as something that just highlights irritating blemishes. At best its something to add to the already over-long To Do list. At worst something that can be easily ignored.

So how can Patient Opinion turn blemishes into blossoms? How can patient comments help set a thousand flowers blooming? Well the answer here is more than the technology. The latest guidance about how government should use Web 2.0 says that people should be prepared to respond quickly, listen and act. Which as Dan Herman points out on wikinomics blogs is great advice.

But our experience on Patient Opinion is that the only people who aren’t caught in the cross fire of conflicting incentives here are the patients. So the trick is using their energy, enthusiasm, and ideas to drive micro change hundreds of times across the NHS. One early example is allowing people to comment on how the trust has responded – see what one less than pleased punter thinks of the hospital's response to their posting.

No one thought that thousands of people would step up to the mark and help create Wikipedia. Or that there were millions of people just waiting for an on-line auction site. The trick is to find ways to galvanise people’s real enthusiasm for the NHS into a process that involves staff and causes thousands or service improvements to blossom. A good analogy perhaps as creating this culture is probably more like gardening than meeting policy targets or implementing Lord Darzi’s report. Slow, gentle persistent work to get the conditions right. And resisting the temptation to pull everything up by the roots once a day to see how they are doing.

Yesterday the London Evening Standard ran a story on the "nightmare" of maternity care in London, prompted by stories women have shared on Patient Opinion about their bad experiences of giving birth.

For example, Maree calls her experience of childbirth "terrifying, confusing and demeaning". Anonymous 2 found "the showers were flithy and paint was peeling off the wall" where she gave birth. Anon reported "cockroaches in the communal eating area". And today on Patient Opinion, Sam told how she feels that her experience has left her not with post-natal depression, but with post traumatic stress disorder.

To be sure, we hear plenty of stories of extraordinary care too. Often, these too will move us to tears.

But that's not the point. The point is that plenty of women are saying, very clearly and courageously, that their experience simply wasn't good enough - and, in some cases, was actually harmful.

The point is: 15 years after the Changing Childbirth report, surely we can do better than this?