Medical practice

Patients 'good judge of hospital standards'

“Patients are accurately predicting which hospitals have high death rates and super-bug infections when they rate their treatment on a TripAdvisor-style website,” The Daily Telegraph has reported.

Consumers often rate hotels and restaurants online and, since June 2007, NHS Choices has enabled people to rate their hospital care online.

The current story is based on a study of 10,274 mostly positive patient ratings of NHS hospital trusts in England that were left on the NHS Choices website. In this study, the researchers found some correlation between patient ratings and objective measures of hospital quality, including some mortality rates and rates of hospital-acquired infections.

They concluded that hospital ratings on websites such as NHS Choices could be an important development in how quality of healthcare is measured. However, because of the brevity of the report and the nature of the study, it is difficult to draw further conclusions. It’s important to note that the people who have chosen to rate the hospitals online are likely to represent only a minority of the people who experience care across NHS hospitals.

We cannot make conclusions from these findings about the overall standard of care within the NHS.

Where did the story come from?

The study was carried out by researchers from Imperial College London and the University of California, San Francisco. It was funded by a Fulbright Award, the Higher Education Funding Council for England and the National Institute for Health Research. The study was published in the peer-reviewed medical journal Archives of Internal Medicine.

This Behind the Headlines analysis was carried out by Bazian and appears on the NHS Choices website, which provides the hospital comment service and is the source of some of the data used in the study.

The story was covered well by The Telegraph and briefly by the Daily Mirror.

What kind of research was this?

This cross-sectional study examined whether ratings of hospital care, posted on the NHS Choices website, were associated with objective measures of hospital quality such as clinical outcomes, including mortality, and healthcare-acquired infections.

What did the research involve?

The researchers looked at 10,274 ratings left on the NHS Choices website from the start of 2009 to the end of 2010. These ratings included measures of:

  • whether the environment where the person was treated was clean, on a scale of one (dirty) to five (exceptionally clean)
  • whether they were treated with dignity and respect by hospital staff, from “not at all” to “all the time”
  • whether the doctors and nurses involved in their care worked together well, from “never” to “all the time”
  • whether they were involved in decisions about their care, from “not at all” to “all the time”
  • whether they would recommend the hospital

For all 166 NHS acute hospital trusts in England, the researchers compared cleanliness of the hospital environment and infection rates (MRSA and Clostridium difficile infection) recorded by the hospital trusts with mean and median cleanliness ratings left on NHS Choices. For 146 trusts (excluding specialised trusts), the proportion of patients who would recommend the hospital was compared to several clinical outcomes (mortality and re-admission rates).

What were the basic results?

On average, each hospital had 62 ratings left on NHS Choices, the majority of which (68%) recommended the hospital. Positive ratings on the NHS Choices website were associated with:

  • lower overall mortality
  • lower mortality from high-risk conditions
  • lower re-admission rates

However, there was no association between positive recommendations and mortality rates among surgical inpatients with serious treatable complications, or mortality from low-risk conditions.

The average cleanliness rating for hospitals was 3.6 out of 5. Hospitals with better ratings for cleanliness tended to have reduced rates of MRSA and C. difficle infection.

How did the researchers interpret the results?

The researchers concluded that the “results demonstrate a relationship between patients’ website ratings of hospitals and some objective measures of clinical quality, including mortality and infection rates”.

They say that although online ratings of hospital care may have advantages, such as improving doctors’ performance, or disadvantages, such as selection bias, the study had shown that they “may be a more useful tool than previously considered for both patients and health care workers”.


This observational research suggests that reviews left on websites such as NHS Choices can be useful and may correlate with some, but not all, objective hospital data on infection rates, mortality and re-admissions. As the Mirror reported, these results suggest online hospital ratings are “not just an online moaning shop”.

Ratings schemes for hotels as well hospitals have been criticised in the past, not least because reviews may be “faked” by people with an axe to grind. For example, in February 2012, the BBC reported that users of TripAdvisor “might be fooled by fraudulent posts since the entries could be made ‘without any form of verification’”. Some doctors’ representatives have criticised online ratings of patient care. For example, in an article from The Sun in 2008, a spokesman for the British Medical Association likened patient ratings to a “Strictly Come Dancing popularity contest”.

And, despite the current research, arguments against using web-based self-reporting of hospital care still exist. For example, reviews are subject to selection bias because not everyone who visits a hospital leaves a review, and those who do rate hospitals are unlikely to represent the majority of the people who experience care in NHS hospitals.

Limited further conclusions can be drawn from this brief report of cross-sectional data, and no conclusions should be drawn from these findings about the standard of care in the NHS.

Patients can view the ratings and comments on NHS Choices as a guide when choosing a hospital, but should remember that individual accounts are based on personal experience. If you are making a decision about which hospital to choose, you might consider a range of factors such as waiting times, how far it is from your home, and even the availability of car parking, all of which are available on NHS Choices.

The first step for any complaint about NHS hospital care should be the individual hospital trust’s complaints procedure.

NHS Attribution