Introduction

Alongside clinical effectiveness and safety, providing a good experience of care is an essential part of an excellent health and social care service.

A person’s experience starts from their very first contact with the health and care system, right through to their last, which may be years after their first treatment, and can include end-of-life care. In addition, it is also important to understand and learn from people who do not currently access services but who have a need to, ensuring that the service provided understands and meets the needs of the community as a whole.

This framework combines policy guidance with the reasons the Care Quality Commission (CQC) most frequently give for rating trusts as ‘outstanding’, based on our review of CQC reports from 2018 to 2023.

The framework should be used in line with NHS IMPACT, the single, shared NHS improvement approach. It can be adapted to meet local population, staff and volunteer needs.

Improving experience of care is not simple. In addition to effective leadership and a receptive culture, organisations need a whole systems approach to listening, collecting, analysing, learning and using feedback for continuous improvement.

Without such an approach, it’s impossible to have confidence that efforts to improve quality are focused on what matters most or would make the biggest difference to experiences of care.

Purpose of the framework

This framework can be used as a tool to improve outcomes and experiences for people using services, unpaid carers, staff, volunteers and communities as a whole.

As a voluntary, self-assessment tool, it will help provider organisations to:

• strengthen a culture of listening to encourage continuous improvement
• use an in-depth experience of care diagnostic tool to support organisational development
• improve the ability to deliver high-quality experience of care for staff, volunteers and people using services, as well as unpaid carers
• begin an ongoing process to better understand experiences of care
• work in partnership with people using services, unpaid carers, communities and the integrated care system, including voluntary and community sector partners
• learn from people who do not currently access services but have a need to or are expected to in the future

Who can use the framework?

This framework supports NHS trusts, foundation trusts and independent providers of healthcare.

NHS England has updated the framework with provider heads of patient experience and policy leads as a response to requests for an updated organisational diagnostic tool.

It can also be used by integrated care boards (ICBs) to better understand how providers across the system are listening, valuing, understanding and improving experiences of care in partnership with other stakeholders, for example, voluntary, community and social enterprise organisations (VCSE).

Some examples of potential users and how they can use this framework are given below:

The level of support provided by systems and regions in applying the framework will depend on the provider organisation’s NHS oversight framework segmentation.

• Segment 1 can self-administer the experience of care improvement framework.
• Segment 2 will receive targeted support from either an ICB or regional team (as applicable) to improve experience of care where specific issues are identified.
• Segment 3 will receive support from the ICB or regional team (as applicable).
• Segment 4 will receive support from the Recovery Support Programme (RSP).

Development of the framework

NHS England has updated the 2018 patient experience improvement framework in line with strategic policy and following feedback from those using the improvement tool.

The name has been changed to the Experience of care improvement framework to reflect the experiences of communities more broadly including those who do not currently access services but have a need to, volunteers, unpaid carers as well as those people who are currently and directly accessing care.

78 provider organisations have helped shape the renamed experience of care improvement framework. Those involved include acute, mental health, community, specialist and ambulance trusts. The revised assessment also draws on the following reports and insights:

• the CQC reports from 2018 to 2023, which provided the evidence base across key areas:
  • CQC reports covering 2018 to 2023 for outstanding (N =19) and inadequate (N = 2)
  • CQC reports covering 2018 to 2023 that were rated requires improvement and placed in special measures for quality or finance (N = 21)
• the National Quality Board guidance
• feedback about the Friends and Family Test
• Patient Led Assessments of the Care Environment (PLACE) 2018 to 2023
• board minutes for outstanding and inadequate organisations
• policy leads in the People and Communities Division at NHS England
• members of the HoPE network (an inclusive professional community working towards improving experiences of care for all)

Framework review

The experience of care improvement framework will have a review period of every 3 years. To contact us, please email us at england.peopleandcommunities@nhs.net.

Overview of the framework

This framework helps providers focus on the key areas (including supporting practice) that must be present to ensure continuous improvement in experience of care.

It brings together the characteristics of organisations that consistently improve experience of care and enables boards to carry out an organisational diagnostic against a set of indicators.

The 5 sections

The framework enables organisations to identify their current position across 5 sections. This can then be used to strengthen a listening culture to drive improvement in experience of care.

Setting up the improvement framework review group

Providers should establish a review group to work in partnership to complete and review the framework. This work involves co-developing next steps and reporting to the trust board as part of the experience of care oversight and assurance.

When establishing the group, it’s important to listen to a broad range of perspectives, such as:

• clinical leaders from all professions
• the executive director lead for the experience of care/quality function
• non-executive directors, governors, foundation trust members
• relevant service leads, clinical, administrative and support staff
• people using services and unpaid carers
• local Healthwatch
• staff from the following areas:
  • governance
  • experience of care
  • data and analytics
  • PALS
  • complaints
  • communications and engagement
  • bereavement
  • chaplaincy
  • quality improvement
  • human resources and organisational development
  • data analysis
• partners from voluntary and community sector organisations
• partners from ICBs and wider system

Using the framework in practice

The review group should consider all areas in the framework assessment tool of this guidance. They are organised under the framework’s 5 sections.

We have developed a worksheet (see appendix 2) to record discussions and agreed actions for future work.

These discussions should look at:

• Where are we now?
• What would good look like?
• What will we do to get from where we are now to what good looks like?

The review group can use the matrix to agree a baseline assessment of current practice against the areas. This review will help identify:

• areas of strong practice
• areas in need of improvement
• areas where consistency can be improved

Together, these will provide the basis of an improvement plan for experience of care. Appendix 1 signposts policies and guidance to help providers develop and improve their practice.

The provider should agree how it will regularly and effectively report progress against their improvement plan through quality governance routes including to trust board. Using the maturity matrix during these reviews will help track any progress and enable boards and senior leadership teams to be sighted on progress and take action if required.

It’s important to remember that this framework does not assess an organisation’s performance. It provides a way to be honest and reflective about what currently works well and which areas need to be prioritised for improvement.

Each organisation’s self-assessment will act as a guide or prompt for conversations about organisational development. It may also be used to support conversations with ICBs.

Experience of care improvement framework assessment tool

Review groups should consider each area detailed under the 5 sections. Use the worksheet to record discussions and actions.

Section 1: Leadership

This section includes the following areas of practice:

• strategic influence of the community, people using services and unpaid carers
• leadership development
• senior leadership influence and support
• clinical, professional and volunteer engagement

Area 1a: The provider has an experience of care strategy that:

• is either a stand-alone document or is integrated into a strategy for improving quality
• has been co-produced with the community, people using services, unpaid carers, frontline staff and volunteers
• has been consulted on with key stakeholders, including the community and voluntary sector and the integrated care system partners
• has been signed off by the board
• is reviewed regularly by the board who can support improvement and mitigating actions

Area 1b: The provider has a delivery plan for experience of care that includes:

• listening to, collecting and ongoing analysis of both quantitative and qualitative feedback from a variety of local and national sources, including from those in the community who do not currently access services but have a need for them or are likely to in the future
• a timetable for review

Area 1c: The provider can demonstrate how it works with people using services, unpaid carers, communities and how this informs relevant decisions, in line with the statutory guidance working in partnership with people and communities.

Area 1d: The provider can demonstrate an approach that addresses inequalities in experience of care and both understands and meets the needs of marginalised or underserved communities.

Area 1e: Where it has identified health inequality gaps between actual and expected service use, the provider can demonstrate:

• how it is working with people who don’t currently access services but have a need to or are likely to need it in the future
• how this work informs relevant decisions

Area 1f: The provider can demonstrate that it’s proactively working with the community to understand the reasons behind any difference between actual and expected experience of care and is seeking to improve it.

Area 1g: The provider can demonstrate how it is working in partnership with the local integrated care board and system to improve experience of care.

Area 2a: The provider can demonstrate that experience of care, for both people receiving and providing care, is embedded in all aspects of leadership development.

Area 2b: The provider can demonstrate how it has involved people using services and unpaid carers in the assessment and appraisal processes for staff. This approach could involve using experience of care feedback data or other forms of evidence, including compliments, complaints and testimonials.

Area 2c: The provider ensures that experience of care feedback from the community, people using services and unpaid carers is embedded in the organisation’s approach to staff and volunteer training.

Area 3a: The provider has an executive director lead for experience of care who routinely provides the board with reports and proactively leads this area of work.

Area 3b: The provider’s executive leadership team is accessible and visible in the organisation and routinely engages with the community, people using services, unpaid carers, staff and volunteers.

Area 4a: The provider can demonstrate how all healthcare professionals are engaged and provide input into the improvement of services, efficiency changes and how changes impact everyone’s experience of care.

Area 4b: The provider can demonstrate how it proactively engages with and involves staff networks, such as the LGBTQIA+ staff network and the network for Black and ethnic minority staff.

Area 4c: The provider understands how change impacts on people using services, unpaid carers, volunteers and staff and considers this in the planning and implementation of transformational activity.

Area 4d: The provider can demonstrate how healthcare professional and volunteer engagement across the integrated care system are focused on people using services and unpaid carers.

Area 4e: There is clear medical engagement in experience of care as an equal facet of the quality agenda alongside safety and clinical effectiveness.

Section 2: Organisational culture

This section includes the following areas of practice:

• organisational development
• supporting staff engagement
• staffing levels
• organisational values
• communications and accessible information

Area 5a: The provider integrates the experience of the community, people using services, unpaid carers, staff and volunteers within its organisational development strategy.

Area 6a: The provider supports staff to listen and act on the feedback from people using services and unpaid carers.

Area 6b: The provider routinely compares and combines feedback from different sources to get a complete picture of the experience of care. These sources include the community, people using services, unpaid carers, staff and volunteers.

Area 6c: The provider supports, resources and actively engages with staff networks when delivering its approach to improving experience of care, for example, the LGBTQIA+ staff network and the network for Black and ethnic minority staff.

Area 6d: The provider monitors the improvements and impact made against staff survey results.

Area 6e: The provider uses positive reporting to identify and celebrate the achievements of staff and volunteers.

Area 7a: The provider can demonstrate that staff are engaged in the process of setting staffing levels and in developing the workforce.

Area 7b: The provider can show how well escalation processes are defined and embedded throughout the organisation to ensure safe staffing.

Area 7c: The provider can demonstrate that staff give care that is compassionate.

Area 7d: The provider can demonstrate that staff involve people using services and unpaid carers in making decisions about their care and treatment.

Area 7e: The provider can demonstrate that it provides good emotional, spiritual and religious support to people using services, unpaid carers, staff and volunteers.

Area 8a: The provider has a set of values that have been co-produced with people using services, unpaid carers, volunteers and staff.

Area 8b: The provider refers to its values in all corporate documents, which reflect the broader values in the NHS Constitution.

Area 8c: The provider has an accountability framework to ensure its values are demonstrated by staff and volunteers.

Area 8d: The provider has a values-based recruitment and appraisal system in place.

Area 9a: The provider can demonstrate that the information it provides is accessible and clear to people using services, unpaid carers and the public, and ensures it is available through multiple routes.

Area 9b: The provider can demonstrate that it identifies, records and shares the communication and information needs and preferences of people receiving care and unpaid carers.

Area 9c: The provider co-produces communications with people with lived experience and other stakeholders to ensure communications are clear and readily understood.

Section 3: Collecting feedback

This section includes the following areas of practice:

• qualitative and quantitative feedback, from a variety of sources: for example, Friends and Family Test (FFT), patient experiences, national surveys
• complaints
• Patient Advice and Liaison Service (PALS)
• ecalation and Duty of Candour

Area 10a: The provider can demonstrate a comprehensive programme of seeking rapid and real or near real-time feedback from people using services and unpaid carers.

Area 10b: The provider can demonstrate an effective approach to collecting and hearing feedback from marginalised or underserved communities.

Area 10c: The provider can demonstrate that there is a process to collect and hear feedback from volunteers.

Area 10d: The provider can demonstrate it supports and uses national patient experience surveys and the Friends and Family Test. It ensures all people who use services and unpaid carers are given the opportunity to feedback, see the results, support co-produced improvements and see the impact locally.

Area 10e: The provider can demonstrate that it uses existing quantitative and qualitative datasets that speak to experiences of care, before beginning to collect new data. This approach will ensure any new data collection is necessary and targeted at evidenced gaps in insight.

Area 10f: The provider can demonstrate adherence to best practice guidelines for experience of care.

Area 11a: The provider undertakes stakeholder mapping to seek feedback from all relevant groups and communities, ensuring no one is missed and everyone’s accessibility and inclusivity needs are considered.

Area 11b: The provider can demonstrate its adhering to statutory guidance for improving the quality of care.

Area 11c: The provider is proactive in informing and signposting people to the range of ways they can provide feedback, including through the NHS website and other organisations, such as Healthwatch.

Area 11d: The provider employs a range of methods to collect feedback, considering accessibility and based on the recorded needs and preferences of people using services and unpaid carers.

Area 11e: The provider employs a range of methods to collect feedback from people who do not currently access care but who have a need for it or would be likely to need it in the future.

Area 11f: The provider empowers staff to actively identify and record communication and information needs and preferences made by people using services and their unpaid carers.

Area 12a: The provider has an accessible and user-friendly complaints policy, which complies with statutory regulations. Information is visible in all locations where care is received and is available from community staff where applicable.

Area 12b: The provider clearly displays information on how to make a complaint on its website, and this is accessible within no more than two clicks from the home page.

Area 12c: The provider offers a discussion with a named contact and complainants are supported throughout the complaints process.

Area 12d: The provider can provide evidence that practice has changed following complaints.

Area 12e: The provider monitors insight arising from complaints, such as patterns and notable variations in experiences of care, to support understanding of and reduce health inequalities, ensuring improvements are sustained.

Area 13a: The provider provides information about Patient Advice and Liaison Service (PALS) that is visible in all locations where people use services and is available from community staff where PALS is provided.

Area 13b: The provider clearly displays information about how to use PALS on its website and this information is accessible within no more than two clicks from the home page where PALS is provided.

Area 13c: The provider routinely gathers and reports on feedback about how issues have been handled where PALS is provided.

Area 13d: The provider can provide evidence that practice has changed in response to feedback from PALS.

Area 13e: The provider monitors insight arising from PALS, such as patterns and notable variations in experiences of care, to support understanding of and reduce health inequalities, ensuring improvements are sustained.

Area 13f: The provider routinely captures a range of written and spoken qualitative feedback, including through lived experience, focus groups and existing datasets, such as the NHS website.

Area 13g: The provider monitors and evaluates the impact and outcomes from quantitative and qualitative evidence as to the experience of care.

Area 13h: The provider can demonstrate it uses both quantitative and qualitative evidence about the experience of care at board level and in committees that support improvements

Area 14a: The provider supports staff in addressing concerns raised by people using services, unpaid carers, families and volunteers.

Area 14b: The provider has a process for demonstrating how teams can share and learn from responding to concerns raised by people using services, unpaid carers, families and volunteers.

Area 14c: The provider can demonstrate that Duty of Candour regulations are well understood and embedded; the provider’s processes are clear and transparent.

Section 4: Analysing feedback

This section includes the following areas of practice:

• quantitative and qualitative analysis
• quality assurance
• governance
• delivering improvement
• action and service redesign

Area 15a: The provider can demonstrate that it routinely and systematically analyses quantitative feedback using appropriate methods and best practice, such as ensuring data is representative and statistical uncertainty is measured.

Area 15b: The provider can demonstrate that it routinely and systematically analyses qualitative feedback using appropriate methods and best practice. This includes not attempting to apply quantitative analysis to qualitative datasets, which will result in a loss of meaning and insight.

Area 15c: The provider has dedicated analysis and support to ensure it can best use its experience of care feedback data.

Area 15d: The provider ensures that analysing experience of care data is a key component of annual quality accounts.

Area 15e: The provider’s quality accounts include information about experience of care and how the trust is listening and responding to feedback from the community, people using services and unpaid carers. This should include examples of improvements to services or care the provider has made as a result of feedback.

Area 16a: The provider highlights areas where experience of care correlates with other quality measures (for example, safety and clinical outcomes).

Area 16b: The trust board reports clearly to articulate the relationships between the quality measures (experience of care, safety and clinical outcomes) and quality improvement.

Area 17a: The provider monitors qualitative and quantitative data from staff, volunteers, communities, people using services and unpaid carers to identify variations and areas for improvement relating to experiences of care.

Area 17b: Staff and volunteers within the provider are empowered to use feedback to inform continuous improvements in line with NHS IMPACT.

Area 18a: The provider has a process to support staff to continually improve how they gather feedback so they can use this to improve the quality of care.

Area 18b: The provider expects all teams to routinely use qualitative and quantitative data feedback about care experiences to make improvements.

Area 18c: The provider has an effective approach to sharing learning locally, including recognising and rewarding good practice and identifying opportunities to improve the quality of care.

Section 5: Learning for improvement

This section includes the following areas of practice:

• care planning and shared decision-making
• staff appraisal
• service change
• co-production
• quality improvement

Area 19a: The provider uses shared decision-making tools to help people using services and unpaid carers make informed decisions about treatment and care options.

Area 19b: The provider has a process for demonstrating that people using services and unpaid carers are all involved in care planning, including the statutory duty to involve unpaid carers in discharge planning.

Area19c: The provider can demonstrate that people using services and unpaid carers, understand any roles they may have in the agreed care plan.

Area 19d: The provider performs highly in those NHS-mandated national survey questions that ask if people felt involved in decisions about care and treatment.

Area 20a: The provider has a systematic approach to identifying staff and volunteer training needs to use feedback to drive improvement in experience of care.

Area 20b: The provider’s board and executive team have a good understanding of how change happens in complex systems, and how change impacts people using services, unpaid carers, volunteers and staff.

Area 21a: The provider can demonstrate that staff engage in continuous improvement using an improvement methodology in line with NHS IMPACT.

Area 21b: Staff have the capability and capacity to identify areas for quality improvement and undertake these improvements in partnership with people with lived experience.

Area 22a: The provider can demonstrate that results of impact assessments are always included within proposals.

Area 22b: The provider can demonstrate how people with lived experience and unpaid carers have been involved at all stages of any service change, and there is evidence of meaningful co-production or co-design within this.

Area 23a: The provider can demonstrate that staff and volunteers are given the opportunity to contribute and act on ideas for continuous improvement, including recognising and rewarding where staff and volunteers have responded positively to experience of care feedback.

Appendix 1: Supporting policies and evidence

Section 1: Leadership

• Improving experience of care: A shared commitment for those working in health and care systems (2022)
• Working in partnership with people and communities: statutory guidance (2022)
• National Quality Board: Shared commitment to quality (2021)
• National Health Service Act 2006
• NHS Oversight Framework, including oversight metrics
• National Institute for Health and Care Excellence guidance – Patient experience in adult NHS services: improving the experience of care for people using adult NHS services
• Public Sector Equality Duty (2012)
• Resources on equality, diversity and inclusion (NHS England SharePoint)
• Guidance and other resources to support implementation of the Public Sector Equality Duty in England: Public Sector Equality Duty: guidance for public authorities – GOV.UK
• NHS Race and Health Observatory – Ethnic Inequalities in Healthcare: A Rapid Evidence Review (2022)
• NHS England resources to support work with local people and communities

Section 2: Organisational culture

• The future of NHS human resources and organisational development (2021)
• NHS Constitution (published 2012, updated 2023)
• Putting compassion at the heart of healthcare
• Accessible Information Standard guidance and supporting resources
• Links between NHS staff experience and patient satisfaction (2018)
• The NHS Patient Safety Strategy (2019)

Section 3: Collecting feedback

• CQC NHS Patient Survey Programme: NHS Surveys – Focused on patients’ experience
• CQC Meeting the accessible information standard: Meeting the Accessible Information Standard – Care Quality Commission
• NHS England National Quality Board: Improving experience of care
• Friends and Family Test
• NHS England complaints policy
• What is PALS (Patient Advice and Liaison Service)?
• NICE guidance – Supporting adult carers
• Maternity and neonatal voices partnership guidance
• CQC (2023): Care Quality Commission
• The Health Foundation: Measuring patient experience

Section 4: Analysing feedback

• Office for Health Improvement and Disparities (OHID): Statistics at OHID
• NHS England National Quality Board guidance on quality accounts: Quality accounts requirements
• Making data count guidance (2021)

Section 5: Learning for improvement

• NHS England resources on personalised care
• NICE guidelines – Shared decision making
• NHS delivery and continuous improvement review: recommendations
• Leading Change, Adding Value: A framework for nursing, midwifery and care staff
• Co-production resource toolkit
• Always Event® methodology and toolkit
• NHS Impact (Improving Patient Care Together) – the new, single, shared NHS improvement approach

Appendix 2: Worksheet

The improvement framework review group can use this worksheet to guide discussion and record actions relating to each area. The maturity matrix can help make a baseline assessment.

Publication reference: PR1209