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Friday 30 September 2016
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Complaints handling in a reforming NHS

Insight: Legal

The zeitgeist behind the government’s reforms of health and social care in England is the ongoing quest for quality, with person-centred care at the heart of service delivery. Whether the proposed legislation will achieve this aim is currently the subject of fierce debate. However, as healthcare providers seek to drive up standards in all areas of their work, within strict budgetary constraints, outcome measures to validate the effectiveness of new approaches become ever more important.

Feedback from patients and service users, and their relatives or carers, is integral to this process and is derived from a wide range of sources – including complaints.

At the time of writing, the Health and Social Care Bill has not yet received Royal Assent but the subject of complaints has been raised and debated as part of the process of parliamentary scrutiny. Ensuring that lessons are learnt from complaints, as well as safety incidents, is seen as vital to the work of the NHS Commissioning Board (NHS CB), as well as clinical commissioning groups (CCGs), in effecting continuous improvement in safety, clinical outcomes and patient experience. The Health Select Committee’s recent inquiry into complaints and litigation also emphasises that “commissioning authorities have the potential to be the engines that drive improvement in the complaints system.”(1)

The complaints procedure, introduced in 2009, was designed to promote good complaints handling in relation to both health and social care by simplifying the process and focusing on resolving the issues at the earliest opportunity.(2) The current arrangements also give complainants the option to raise complaints in the first instance with the service’s commissioner instead of with the provider organisation about which they are complaining.

Allowing choice in this way, and promoting a positive view of complaints handling that focuses on the needs of the complainant and requires organisational improvement and learning, are general principles that will transfer to the new structures.

It is likely, therefore, that the present two-stage complaints framework will remain and, where local resolution (the first stage) fails to bring about a resolution of the complaint, the complainant will then be able to request an independent review of their complaint by the Parliamentary and Health Service Ombudsman (the second stage).

If, as planned, primary care trusts (PCTs) are replaced as commissioners of primary care services, their role in relation to primary care complaints will pass to the NHS CB. Exactly how the NHS CB will manage this process at a local level is yet to emerge, although this is seen as a key area in the board’s development of local operating systems.

As at present, the different commissioning bodies will have access to complaints information for monitoring purposes that will enable them to identify emerging trends, ensure lessons are learnt, service improvements are made and consumer concerns acknowledged appropriately.

Strongly allied to this is the role of HealthWatch England and the local HealthWatch. These new consumer champions will highlight the experiences and views of patients and service users in relation to complaints handling, and recommend ways in which the relevant services can be improved. Any organisation, whether a provider or commissioner of health or social care, found to have poor complaints handling will have a statutory duty to respond appropriately to the local HealthWatch body (see Box 1).

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Like the NHS CB, CCGs will need to handle complaints relating to their own functions, as well as complaints about provider organisations whose services they commission. Although CCGs will not be commissioning primary care services themselves, they will be actively supporting the NHS CB in its role to do so. They will have a duty to promote quality improvements in their member practices, and in this respect patient feedback will be an important source of information.

In her annual report of complaints handling by the NHS in England 2010-11, the Parliamentary and Health Service Ombudsman warns: “When feedback is ignored and becomes a complaint it risks changing from being an asset to a cost.”
In the year under review, the Ombudsman’s office “secured nearly £500,000 for patients to help remedy injustice caused by poor care and poor complaint handling.”(3)

Communication and engagement
Although some practices pride themselves on their approach to complaints handling, some fall far short of the required standards. The Ombudsman commented: “As GPs prepare to take on greater responsibility for commissioning patient services, this report provides an early warning that some are failing to handle even the most basic complaints appropriately.” Poor complaints handling is often caused by poor communication, cited as a key theme in the Ombudsman’s report.

Successful commercial organisations renowned for high-quality customer service encourage their staff to view complaints as “gifts” not “threats”. They recognise that as well as giving them a competitive edge by retaining customer loyalty and protecting their reputations, good complaints handling can also help prevent mistakes, improve standards and quality, and highlight safety or performance concerns.(4)

Good complaints handling involves:

  • Acknowledging concerns and complaints promptly.
  • Apologising sincerely for mistakes or shortcomings.
  • Conducting face-to-face meetings in a way that is supportive and non-adversarial.
  • Giving clear and unambiguous explanations that are jargon-free and address all aspects of the complaint.
  • Providing redress or remedy where appropriate.
  • Sharing with the complainant any actions to be taken as a direct result of the complaint.

Engagement with all staff is vital if you want to encourage a positive and proactive approach to complaints handling in your practice. Central to this will be the priority you give to training and awareness raising, including recognition that complaints handling is an important component of risk management.(5)

Responding appropriately to a complaint is an essential skill; individual staff development plans and appraisals can provide a good opportunity to address this. Case studies and scenarios can also be valuable aids in helping you to achieve what may, in some cases, be a radical shift in culture.

You cannot overestimate the extent to which a poor response to a complaint can affect a patient’s perception of their healthcare, overshadowing what might otherwise have been a positive experience. Are you confident that your practice:

  • Actively welcomes patient feedback, including concerns and complaints?
  • Provides clear and accessible guidance for patients on how to complain, both inhouse as well as on your practice website?
  • Supports complainants appropriately; for example, by highlighting how they can access independent advocacy?

Complaint-handling culture
You should be supported in your role as complaints officer and the practice should regularly review complaints to ensure:

  • Adherence to the complaints procedure.
  • Appropriate investigation of complaints.
  • Prompt action as a result of any investigations.
  • Identification of any trends or learning points.

Encouraging feedback from complainants about your complaints process and their experience of it is also important. Too often, complaints that have been handled badly result in an escalation of the issues and compound the complainant’s original grievance. The consequences of poor complaints handling not only impact on the complainant; they can have serious and deleterious effects for the staff involved, both at a personal level and also on their professional relationships with future patients.(6)

Being aware that seemingly trivial issues can escalate will enable you to take pre-emptive action and help to prevent a complaint from causing damage to the individuals directly involved, as well as to the practice’s reputation and the confidence of other patients in the services you provide.
Conciliation is a valuable resource for primary care. It can be helpful in relation to seemingly intractable or complex complaints and can also facilitate the restoration of deteriorating clinical relationships that might otherwise result in formal complaints.

The key features of conciliation are:

  • It is a confidential, impartial process that can be supportive to the health professional as well as to the complainant.
  • It can be used in relation to complex clinical complaints as well as those relating to the attitude and manner of staff.
  • It is not essential for the parties to meet in order for the complaint to be resolved, unless restoration of a clinical relationship is a desired outcome.
  • It can provide an opportunity for:
    - Underlying issues to be explored.
    - Explanations to be given, where necessary involving independent clinical or specialist advisers.
    - Apologies to be made.
    - Redress to be offered.
    - Actions to be identified that will lead to service improvements.

Apart from poor communication, another outstanding theme in the Ombudsman’s recent report is also of direct relevance to practices. This relates to a small but increasing number of complaints about the removal of patients from a GP’s list of registered patients.(3) The Ombudsman’s investigation of these complaints highlighted a number of issues relating to:

  • Failure to follow the correct processes – for example, removal without prior warning when the situation did not justify this.
  • Removal from the list as a direct consequence of the patient raising concerns or complaints.
  • The impact on the patient or family members in terms of their healthcare, as a result of the disproportionate practice response to difficulties arising in the clinical relationship.(3)

Judicious use of conciliation might have prevented the situations that gave rise to some of the complaints later upheld by the Ombudsman. The case study in Box 2 gives an example of this, and highlights the role of the practice manager when removal of a patient from the practice list is under consideration.

Whatever changes in complaints procedures result from the Health and Social Care Bill, the fundamental principles of good complaints handling will remain. In preparing for the challenges ahead, practices will be well placed if managers seek to make listening and responding to patient feedback, including complaints, a practice priority.

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Anne Ward Platt is director of a management consultancy specialising in the healthcare sector and writes on health and management issues. An experienced conciliator, she is the author of Conciliation in Healthcare: managing and resolving complaints and conflict. Anne has served as an Audit Committee Chairman in her role as a non-executive director in the NHS. She is Deputy Chair of Northumberland, Tyne and Wear NHS Foundation Trust.

References
1. House of Commons Health Committee. Complaints and Litigation: Sixth Report of Session 2010-12.  London: The Stationery Office Limited; 2011.
2. Statutory Instrument 2009 No. 309. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.
3. Parliamentary and Health Service Ombudsman. Listening and Learning: the Ombudsman’s review of complaint handling by the NHS in England 2010-11. London: TSO; 2011.
4. Ward Platt A. Handling complaints. BMJ 2010;340:98-9.
5. Ward Platt A. Take careful steps to minimise risk in 2010. Management in Practice 2010;20:22-5.
6. Jain A, Ogden J. General practitioners’ experiences of patients’ complaints: qualitative study. BMJ 1999;318;1596-9.

Resources

Care Quality Commission
www.cqc.org.uk

HealthWatch
www.cqc.org.uk/public/about-us/partnerships-other-organisations/HealthWatch

Parliamentary and Health Service Ombudsman. Principles of Good Complaint Handling
www.ombudsman.org.uk/improving-public-service/ombudsmansprinciples/principles-of-good-complaint-handling-full

NHS Information Centre. Data on Written Complaints in the NHS 2010-11.
www.ic.nhs.uk/statistics-and-data-collections/audits-and-performance/complaints/data-on-written-complaints-in-the-nhs-2010-11

NHS (Personal Medical Services Agreements) Regulation 2004.
(Schedule 5, part 2, sections 18-27, outlines provisions for removal of patients from a GP practice list) www.legislation.gov.uk/uksi/2004/627/contents/made

RCGP. Removal of Patients from GPs’ Lists – Guidance.
www.rcgp.org.uk/PDF/Corp_removal_of_patients_from_gp_lists1.pdf