Every healthcare provider collects feedback. Far fewer ask the harder question: whose feedback are we actually collecting?
The assumption behind most patient feedback programmes is that responses represent the wider patient population. The evidence says otherwise. Every collection method — the format, the timing, the effort required — filters who responds. A survey emailed three days after an appointment doesn’t capture “patient experience”. It captures the experience of patients who are online, confident with forms, and still motivated to reply three days later.
That is a narrower group than most providers realise.
The scale of the gap
The House of Lords Communications and Digital Committee reported in 2023 that around 2.4 million UK adults cannot complete a single basic digital task, and roughly 31% of people over 65 — about 3.9 million people — do not use the internet at home. These are not marginal numbers, and they skew heavily towards the people who use health services most.
The pattern shows up in behaviour, too. Research commissioned by LINK found that booking a healthcare appointment was the single most common everyday task people still preferred to do offline. If patients won’t book digitally, expecting them to give feedback digitally — later, unprompted, via a link — is optimistic.
And digital exclusion is only the most measurable barrier. Cognitive load, stress, communication difficulties, low literacy and simple time pressure all raise the cost of responding. This affects neurodivergent people, older patients, people with cognitive impairments, and anyone leaving an appointment with more urgent things on their mind than a questionnaire.
The critical point: a missing response is not a neutral response. Silence is not satisfaction. Often it just means the process asked too much.
Why this is a data quality problem, not a compliance problem
Accessibility in feedback is usually framed as a duty — and in healthcare it partly is. The NHS Accessible Information Standard has required providers to identify and meet patients’ communication needs since 2016, and the CQC expects providers to show they seek out the views of people who are less likely to speak up, not just those who volunteer.
But the stronger argument is about the quality of the evidence providers act on.
NHS England’s own review of the Friends and Family Test acknowledged that longer questionnaires depress response rates and that inconsistent collection methods introduce bias that undermines comparability. Qualitative research with GP practice staff found they lacked confidence in FFT results precisely because the samples weren’t representative. High response volumes don’t fix this. A thousand responses drawn from the same easy-to-reach group is still a partial picture — it’s just a partial picture with a convincing sample size.
Decisions built on that data inherit its blind spots. If the patients facing the greatest barriers to feedback are also those facing the greatest barriers to care — and the digital exclusion data suggests they often are — then the feedback least likely to arrive is the feedback providers most need.
What actually widens participation
Two design principles do most of the work.
1) Capture feedback at the point of experience.
Asking in the moment — before the patient has left the building — removes some of the biggest sources of drop-off: the delay, the email, the need to remember and the effort of finding time later. The experience is still fresh, and responding becomes a simple part of the patient journey rather than another task to complete afterwards.
2) Make responding almost effortless.
Better insight rarely comes from asking more questions. It comes from lowering the barrier to participation: fewer steps, clearer language and feedback methods that do not assume digital confidence or spare capacity. A response method that works for a wide range of patients is not a compromise; it is a way of improving the quality and representativeness of the data collected.
This principle is already being demonstrated in practice. At The Edinburgh Practice, the challenge was not a lack of willingness from patients to provide feedback; it was the limitations of the existing process. By introducing a more immediate, accessible approach to capturing patient views, feedback became easier to give and more closely connected to the patient experience itself. The result was a broader range of patient voices being captured, providing the practice with richer insight than traditional follow-up methods alone could achieve.
The lesson is important: improving feedback does not always mean asking more people to complete the same survey. Often, it means removing the barriers that prevent people responding in the first place.
The reframe
The instinct, when certain groups don’t respond, is to ask what’s wrong with the outreach. The better question is what’s wrong with the process. Most patients are willing to be heard. Whether they are heard is a design decision — and it’s one providers control.
Providers that remove those barriers don’t just collect more feedback. They collect feedback they can actually trust to represent the people they serve.
