Indicates required field In just three minutes, you can make a difference.Share your views on health or social care services. Tell us what works and what needs improvement.It's confidential, quick and won't affect your care. But your experience will help us tell NHS and social care services how to make your care better.This survey is also available in Easy Read.We’d love to keep you updated about our work and the difference sharing your experiences with us can make. Complete the survey 1. Choose the area of care you would like to tell us about? Please select the options that you'd like to talk to us about. You can pick more than one. GP services Dentist Pharmacies Hospital inpatient (day treatment or overnight) Hospital outpatients' appointments Mental health support Social care eg care homes, and home care Accident and emergency/minor injury units Ambulances and paramedics NHS 111 Other issue/service (if other, please tell us which issue/service you are referring to) If other, please tell us which issue/service you are referring to 2. Please tell us about your experience What went well? What could have been better? 3. Please tell us the name(s) of the service you used (for example the name of your GP surgery or hospital). eg. the GP surgery name or hospital department 4. How easy was it to access the help and support you needed? - Select -Very goodGoodNeither good nor bad PoorVery poorN/A 5. How would you describe your experience of care? - Select -GoodNeither good nor badPoorI had a mixed experienceDon't know / not sure 6. In relation to this experience please select the statement that best describes you - Select -I am the person who received the careI'm providing feedback on behalf of a friend or relative, or because I'm their carerOther Tell us a bit about you It would really help to know a little more about you so that we can better understand how people's experiences may differ. These questions are completely voluntary. Are you happy to share some information about you? 7. Please tell us your age - None -16 to 17 years18 to 24 years25 to 49 years50 to 64 years65 to 79 years80+Prefer not to say 8. Please tell us your gender 8. Please tell us your gender - None -WomanManNon-binaryPrefer not to sayPrefer to self-describe Enter other… 9. Is your gender identity the same as your sex recorded at birth? - None -YesNoPrefer not to say 10. Please tell us which sexual orientation you identify with 10. Please tell us which sexual orientation you identify with - None -AsexualBisexualGay manHeterosexual / StraightLesbian / Gay womanPansexualPrefer not to sayPrefer to self-describe Enter other… 11. Please select your ethnicity 11. Please select your ethnicity - None -ArabBangladeshiChineseIndianPakistaniAny other Asian / Asian British backgroundAfricanCaribbeanAny other Black / Black British backgroundAsian and WhiteBlack African and WhiteBlack Caribbean and WhiteAny other Mixed / Multiple ethnic groups backgroundBritish / English / Northern Irish / Scottish / WelshIrishGypsy, Traveller or Irish TravellerRomaAny other White backgroundPrefer not to sayAny other ethnic group Enter other… 12. Please select any of the following that apply to you I prefer not to say I have a disability I have a long term condition I am a carer None of the above 13. Which of the following statements best describes your financial status? - None -I have more than enough for basic necessities, and a large amount of disposable income, that I can save or spend on extras or leisureI have more than enough for basic necessities, and a small amount of disposable income, that I can save or spend on extras or leisureI have just enough for basic necessities and little elseI don’t have enough for basic necessities and sometimes run out of moneyI don't know / prefer not to say 14. Pick the area that best describes where you live Tell us which local authority/borough area you live in? (Start writing the name of your local authority/borough and select from the options available) How we use this informationThe information you share with us is completely confidential and will not affect your care. We use this information to help us spot trends to identify areas for improvement. We may use quotes in our reports, but we will not use any information that will identify you. Find out more about how we handle your information in our privacy statement. Can we stay in touch? We'd love to tell your story and keep you updated about our work and the difference sharing your experiences with us can make. Using your story for mediaTo highlight the care issues that people tell us about, we use people’s stories to show what is working and what needs to change. Sometimes the media (newspapers, radio or TV) ask to use our stories in their own materials too. Would you be happy for us to contact you to talk further about your experience to see if we can use it as a case study? I am happy to be contacted by Healthwatch England to discuss whether my story could be used as a case study. Sign-up to our mailing list Sign-up to our mailing list to stay up to date with what people are telling us about health and social care, our advice and information, and our latest reports. You can unsubscribe from our mailing list at any time. I want to join Healthwatch England’s mailing list. Your local HealthwatchWould you be happy for your local Healthwatch to contact you about your submission? I'm happy to be contacted by local Healthwatch about my submission. Name First name Last name Email Submit Leave this field blank
