Last week I talked about Patient Opinion at Alex Stobart's very excellent ScotWeb2 unconference. Lots of very interesting, knowledgeable and motivated people there, so it was a great day.

One or two people wanted the slides, so I've put them on SlideShare and embedded them here:

We're keen to provide a proper Patient Opinion service for patients and carers in Scotland who want to offer feedback about their health care (and we already get stories). One challenging issue, which we are already bumping into elsewhere too, is that there are many, many small hospitals located in very sparsely populated areas.

Why is this a challenge? Because we aim to maintain the confidentiality of those posting on Patient Opinion, and because we don't want to inadvertently defame a member of staff. Suppose we receive a posting about the Royal Isolated Hospital which says: "I was seen at this hospital last week with my genital warts. The nurse I saw was clearly incompetent." So far so good: the patient and staff member are not identified - unless you happen to live locally. In which case you and everyone else round about will know that the only patient seen there in the last month was Iain, and the only nurse at the Royal Isolated Hospital is Margaret.

This doesn't seem desirable - but neither does the option of publishing feedback without saying which service it is about.

We have a few ideas on how we might tackle this - but we're looking for more. Suggestions, please!

When people are ill they want the best care they can get but of course professionals vary in their interests, skills and expertise. So how do you find out who the local expert is?

People imagine that their GP knows all the local consultants and will send them to ‘just the right person’. This is understandable but mistaken. Firstly there are usually several hundred consultants at any one hospital in Britain – keeping up to date with who does what, let alone who is best at what is impossible for GPs.

But even if you’re GP does happen to know who is best, they then have to manipulate Choose and Book, the new mega system to support ‘choice’ which makes it intentionally hard for GPs to use to refer to a particular named consultant. Intentionally because it’s much easier to manage waiting lists when all referrals for a particular specialty or service come into a single pool. So choice is sacrificed to shorter waiting times.

The NHS has traditionally got round this by saying that all services meet minimum standards so you don’t need to find the best. Recently the lameness of this response has triggered an interest in PROMs – Patient Reported Outcome Measures. If we don’t know who is ‘best’ then we’ll ask you, the patient. So PROMs aim to measure how you felt before an operation and then again some weeks afterwards.

The Darzi report, which is this year’s bible on how the NHS should develop, says that we should use PROMs right across the system in the hope this will help people choose who they want to see. And give a valid answer to the question that managers are also very interested in, namely ‘which of our doctors are good?’ (And, by implication, which are less good).

Trouble is that whilst PROMs are useful they are very far from perfect. To make valid judgements about outcomes you need to have a big enough sample and make sure that inputs – the casemix of people seeing different consultants or teams – is the same. If one team specialises in difficult cases their outcomes will be different to those handling easier cases. And of course you need a reasonable number of cases for each procedure and each surgeon. The danger therefore is that PROMs will just mean many more surveys for patients plus a whole new industry processing the answers and tweaking the answers to try and get a ‘true’ picture.

For our part we think that the emphasis on choice is in some ways – literally – misplaced. The 'choice' policy puts the question at the wrong point in the process. Ill people make poor shoppers, and whilst they most definitely want to be involved and informed in decisions they usually want to be looked after rather than labouring under a mountain of 'choice' decisions. Once patients have experienced a particular service (and hopefully are feeling better) they have very decided views about what they liked and what could have been better. Using these views as a quality driver makes much better sense – and is what we try to do at Patient Opinion.

How to give patients accurate, useful information to help them make better choices is an important question that keeps coming round and round like a bad penny. PROMS, Choose and Book, Information Prescriptions, NHS Unlocked, IWantGreatCare all represent different approaches to this problem. Sadly trying to find who is the ‘best’ doctor for some condition or operation is a simple question that can only ever have frustratingly complex answers.

Among all its myriad wonders, one thing the web does well is enable every voice to count. Even the voices of people who don't usually have a voice.

That's been one of the key values driving the Patient Opinion team. And now we're pushing this a little bit further through our partnership with Homeless Link, with our attempt to bring the voices of homeless users of health services into the heart of the NHS.

Will it work? We don't know, but we think it's worth a try. Remember, On the Internet, Nobody Knows You're a Dog.

James has been busy creating big pictures of Patient Opinion postings, and Paul has talked about our recent work with Rotherham Trust, where staff made promises to themselves. We will be publishing those promises on the site in the next few days, but in the meantime here is an interesting combination of our last two blogs.

Here is a Wordle of 50 promises that Rotherham staff have made.

The other day we blogged about "the big picture" of the last 100 postings on Patient Opinion.

So a few people said: "well, OK, but what about the responses from the NHS?" And, obviously, we couldn't resist. So here's a Wordle of the last 100 responses posted on Patient Opinion.

Finding ways to combine these two aspects of great health care, the highly personal and the highly systematic, is the task of health professionals in the 21st century.

Click here if you want to see an example of a story brim full with acts fo work and courage - or here for one that fails on almost every count. 

Sometimes people ask us: so what is everyone saying? Can't you just summarise it all? Don't bother me with all these stories - just give me the big picture.

So here it is, thanks to Wordle. The big picture of our last 100 postings.

Yesterday, Rotherham Hospital held a remarkable, perhaps pioneering, event attended by 80 or so staff from all parts of the hospital, from consultants to security staff, from admissions clerks to pharmacists. During the day, staff reflected on their interactions with patients and relatives by engaging vigorously with a small group of actors who presented a single scenario which could be played, and replayed, with direction from everyone present, until it felt "just right".

The event was called Every Interaction Counts. It was stimulated by a posting on Patient Opinion in which a relative of one of Rotherham Hospital's patients raised concerns about the care his step-father had received in his final days.

The hospital made very speedy and helpful response on the site, avoiding a defensive tone, and followed up with a meeting with family members to hear and respond to the issues raised. The author of the original posting took the trouble to post a very full and positive report of this meeting on Patient Opinion.

From our point of view at Patient Opinion, this is remarkable enough: if all hospitals across the UK were to respond in such an open, sensitive and non-defensive manner, we would be delighted. But more was to come.

Patient Opinion discussed with the hospital how the lessons from this one incident might be shared right across the organisation. At the same time, we were fortunate to receive a private donation specifically for just such a purpose. The result was a day in which a large group of hospital staff participated, reflected, engaged fully with one key difficult, vital, human question: what does it mean to care?

No doubt other members of the Patient Opinion team - especially Paul, who brought the day into being - will also blog with their perspectives. Or they may add postings on the main Patient Opinion site, where we have (a bit of a hack) set up the event so that participants can post their responses and reflect on whether - or how - it changes their daily practice. And in a small way, this is the start of a pilot for a new set of tools we aim to create which will enable staff and patients to work together to change services.

But, for now, it is enough to applaud the leadership and courage of Rotherham Hospital in taking the first, brave steps towards a new way of doing things.

As if by magic, after my blog post yesterday on patient complaints, today sees the release of a National Audit Office report catchily titled Feeding back? Learning from complaints handling in health and social care.

So what does it say? In a nutshell (and I quote):

There is, in particular, confusion as to how to access and navigate the complaints system; lack of public confidence in the system; concern over the time taken to respond to complaints; a failure to find a sustainable and effective independent resolution stage; and limited sharing of lessons within and across NHS bodies.

Among other highlights, the NAO found that:

• only five per cent of people who were dissatisfied about the NHS went on to make a formal complaint
• few trusts capture and report data on complaints in a systematic way
• a fifth of complainants reaching the Healthcare Commission stage simply wanted "an apology or recognition of the event"
• only one third of complainants considered that the organisations they had complained about had demonstrated that lessons had been learned as a result
• in many cases trusts had genuinely learned from complaints but did not tell the complainant

Hmmm... all this feels entirely consistent with yesterday's conclusions. Can Patient Opinion help with all of this? Yes, I think we can.

A rather depressing posting arrived on the Patient Opinion site today.

A sentence near the end sums it up rather well: "How do I complain about the waste-of-time complaints procedure?"

The posting reminded me that the Patients Association had recently published their report NHS Complaints: who cares? who can make it better? So I went off to read it and see how typical this contributor's experience might be.

The Patients Association surveyed 1500 patients for its report, of whom fewer than 500 responded, so there is plenty of room for bias. But one finding caught my eye: of those with experience of using the NHS complaints system, 20% had found the process "pointless" and almost a further 30% had found it "totally pointless". By contrast, about 13% had found it "useful" and a further 2% "very useful".

There is quite a strong message here. Whatever it is that patients are trying to achieve through the complaints system, it evidently fails to deliver for a large proportion. But what are patients trying to achieve?

The report's findings suggest that a large proportion of patients want the system to:

• make sure everyone learns from a mistake
• ensure it doesn't happen to other people
• ensure patient's views are heard in the future
• change clinical behaviour

Interestingly, this fits exactly with our own experience at Patient Opinion. Sometimes a hospital will contact us about a critical posting on our site. "Can you remove it?" they say, "and ask the patient to make a complaint instead?" We don't remove it (of course), but we will email the patient in confidence to ask if they would like to make a complaint. And in every case to date, the patient has replied: "No, I don't want to make a complaint. I'm not trying to get anyone into trouble. I just want the problem fixed so it doesn't happen to anyone else."

Reflecting on this, a series of vague but insistent thoughts are beginning to form:

• Is the number of complaints in the NHS driven by the lack of alternative ways to feed in one's experience?
• Do hospitals drive people towards the complaints process because it is the only institutional system available?
• If other systems were available (you can see where I'm going here) which offered the possibility of being heard, helping people to learn, and making a difference to the service, would patients prefer that to the existing complaints system?
• And what would need to happen (in any system) for the majority of people to say that the process had been "useful" rather than "pointless"?

I might as well be blunt: could Patient Opinion help hospitals move towards a triple benefit: fewer complaints, greater learning from experience, and happier patients? I think we should find out!