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Wednesday 28 September 2016
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Keeping complaints management on track

Insight

FIONA DALZIEL
MA(Hons) CIHM FIHM

Independent Consultant in Practice Management

Fiona is an experienced primary care trainer and facilitator. She is the national RCGP QPA Adviser and has advised on
both the original and the review of the Quality and Outcomes Framework of the 2004 GP contract

Everyone's heart sinks when a complaint from a patient is received. I am not referring to the frustrated patient at the front desk whose request for a repeat prescription has managed to get lost for the second time in a row, but to a formal complaint about the medical care a patient has received. Manage your practice's response to complaints the right way and you will be well on the way to reducing the chances of the complaint being taken further.

The NHS Complaints Procedure
First, a reminder of the NHS Complaints Procedure, which is in two stages: Local Resolution and Referral to the Ombudsman. The procedure includes time limits for complaints and this is usually six months from the date of the incident or six months from awareness that something has gone wrong (as long as this is within 12 months of the date of the incident).

In practice, patients' circumstances may have been such that they would have been unable to complain within the time limit, and in these cases the time limit is usually waived. This might be because of a very severe trauma that caused lengthy incapacity on the part of the complainant or because of circumstances such as a grief reaction.

Local Resolution
The practice must have a complaints procedure. Patients who wish to complain should ask for a copy before complaining or, if they did not do so at the time, should be given one as soon as possible.

The procedure should include the details of how a patient can get assistance with formulating and presenting their complaint. In England, this is provided by the Independent Complaints Advocacy Service (ICAS). In Scotland, the equivalent organisation is the Independent Advice and Support Service (IASS). Citizens' advice bureaus also help to direct patients to this support.

Local Resolution consists of asking the patient to contact the practice, in writing or face-to-face, to explain the complaint to the doctor or nurse concerned. Often, complaints come in the form of a letter to the practice manager.

Depending on availability of the service, an independent conciliator may be able to work with the patient and practice to help resolve the complaint.

Referral to the Ombudsman
Each of the countries has their own ombudsman. Information on each can be found at the following websites:

You should be aware of the following important points relating to how a complaint is assessed by the ombudsman:

  • The ombudsman will only accept for investigation complaints that come under their legal powers and that have already been through Local Resolution.
  • Patients do not have an automatic right to have their complaint investigated. The ombudsman will point complainants in the right direction if they are unable to proceed themselves.
  • The ombudsman considers whether there is evidence of an administrative or service failure. If neither is present, then the complaint will not be investigated.
  • The ombudsman will then investigate whether injustice or hardship has occurred as a result of the administrative or service failure.
  • Next, the ombudsman considers whether an investigation by his/her office will lead to a worthwhile outcome.
  • It may already be clear from the evidence that there has been an injustice that was obviously not put right, and the ombudsman may start to work with both parties to find resolution.

The ombudsman will then investigate if it not clear that an immediate intervention would resolve the matter. This investigation focuses specifically on the complaint. Because all complaints are so different, the final remedy or solution for one complaint may be very different from another, and sample outcomes can be seen in an annual report online.

Legal claims or professional misconduct
The NHS Complaints Procedure will normally be halted if the complainant commences a legal claim. However, it is not unheard of for complaints that have completed the NHS complaints procedure to go on and become a legal claim. Likewise, complaints about professional misconduct to the General Medical Council (GMC) will normally not be progressed until the outcome of the NHS Complaints Procedure has been reached.

Ensuring successful local resolution
GPs may realise during patient consultations that a complaint may arise. This is often because the patient's expectations of the service have not been met. At this point, the GP has a crucial opportunity to listen to the patient and stop a complaint from becoming formalised.

It may be possible to invite the patient or a member of their family to come along for a longer appointment to speak through their expectations and voice their disappointment or frustration. Handled empathetically, this is likely to give patients the signal that the practice is concerned, has listened, has apologised and has put measures in place to make sure the same thing does not happen to someone else. Often, having a full explanation and a feeling they have been listened to will be what a complainant is seeking.

In May 2009, the NHS Litigation Authority issued a letter relating to 'Apologies and Explanations'. This was endorsed by several medicolegal organisations, the Royal College of Nursing, the British Medical Association and the GMC, among others.(1)

This letter reassured GPs that apologising for a shortcoming in treatment did not constitute an admission of liability. It encouraged doctors and NHS organisations to offer detailed explanations of what led to the adverse outcome and also to express their sorrow or regret. The provision of information is considered to be good practice, both in clinical and management terms. The letter goes on to encourage doctors to contact their defence union to seek support or clarification in these circumstances.

Several important steps should be followed in order to try to resolve the complaint satisfactorily in the practice and avoid escalation.

Respond within a reasonable timescale
Make sure you acknowledge the complaint within two working days and let the complainant know if the response will be delayed and the reason for this (for example, annual leave).

Make sure you have consent
Complaints on behalf of a family member may need the consent of the patient before you can proceed. At this point, you will wish to ascertain whether the patient is competent and then seek written consent of the patient themselves to investigate the complaint. Occasionally, the patient themselves may be unaware of the family member complaining on their behalf or may not wish to complain themselves, in which case consent may not be forthcoming and the complaint may not proceed any further.

Talk to everyone involved
Meet individually with any doctor(s) involved in the complaint. The receipt of a complaint is a stressful experience for every doctor, even the most experienced. It is vitally important that you not only look after the interests of the patient by collating all the information and responding appropriately, but that you also look after doctor colleagues in the practice who may be upset.

Collate written responses
Many GPs will want to respond to a complaint themselves by investigating and drafting a response with the support of their defence union. In other practices, the manager is able to draft a response on behalf of the GP(s). If several GPs are involved, this is a useful approach. In these circumstances, it is helpful to ask the GP(s) for an initial written report of what happened, based on the patient's record.

Take advice on the draft response
Defence unions are happy to receive (appropriately anonymised) clinical letters and other records, as well as the draft response in order that they can check that the right amount of information is included in the response before it is sent to the patient or complainant.

Make sure you offer to meet
As before, patients wish to be listened to when they are complaining. A written response and explanation may go a good way to answering the complainant's questions, but a face-to-face meeting may finally lay any concerns to rest. An invitation to get in touch to arrange a meeting should be included in the letter of explanation, along, again, with an expression of regret at what has happened (if appropriate).

Understanding patients' wishes
Research into complaints management demonstrates that complainants consider both the outcome of the complaint and how it was handled in their final assessment of what happened to their complaint.(2) Their satisfaction or otherwise with these processes will influence their further behaviour, including decisions about whether to take the complaint further or what they say about the service to others. Additionally, these elements influence the complainant's future relationship with the service provider.

The research found the following two elements were important:
'Cold fact complaint satisfaction' – this includes the adequacy of the solution to the complaint and speed of resolution, ie, process.

'Warm act complaint satisfaction' – this refers to the personal treatment the complainant experienced (ie, how it felt).
'Cold fact' satisfaction was more important in terms of the complainant's satisfaction with the resolution of the complaint than 'warm act' satisfaction. In other words, the process and final outcome were more important to how the patient finally felt than softer elements such as courtesy or empathy.

However, in terms of the complainant's final relationship with the service provider, 'warm act' elements were more important than their overall satisfaction with the outcome of the complaint.

So it really is important to follow the procedure. However, the way in which you do so will have a significant effect not only on how the patient feels about the resolution of the complaint overall, but also on their remaining relationship with the GP. Patients who feel they have been treated with empathy and understanding may well feel less motivated or interested in pursuing a complaint to the (often bitter) end.

References
1. Letter to Chief Executives and Finance Directors, all NHS Bodies, from Stephen Walker CBE, Chief Executive, NHS Litigation Authority, Napier House, 24 High Holborn, London WC1V 6AX. Dated 1.5.09.
2. Stauss B. The dimensions of complaint satisfaction: process and outcome complaint satisfaction versus cold fact and warm act complaint satisfaction. Managing Service Quality 2002;12(3):173-83.

Resource

NHS Complaints
www.nhs.uk/choiceintheNHS/Rightsandpledges/complaints