Providing high quality care involves listening to patients and responding positively to feedback, both positive and negative
The report of the public inquiry chaired by Robert Francis QC into the catastrophic failings of care at Mid Staffordshire NHS Foundation Trust calls on all healthcare organisations to consider its findings and recommendations and how they apply to their own work.1 Central to the report is prioritising the delivery of high quality patient care. This includes listening and responding to concerns and complaints whether they come from patients themselves, their relatives or carers, or from members of staff. Tragically, at Mid Staffordshire there was no culture of listening to patients and there were “inadequate processes for dealing with complaints and serious untoward incidents.”1
An effective complaints system should be an essential component of your practice risk management structure.2 Complaints can highlight safety and performance issues, and allow for mitigating actions to be taken at an early opportunity. Organisations that create barriers to prevent people from complaining, act defensively, or fail to learn the lessons from complaints, risk seriously compromising patient care.
Practice managers have a key leadership role in helping to promote a culture in their practices where:
- Feedback, including concerns and complaints, is welcomed and encouraged from patients, their relatives or carers, as well as from members of staff.
- Complaints are viewed as a valuable resource for maintaining high standards of care.
- Learning from complaints results in positive actions.
With the new NHS structures now in place, practices also need to listen to their patients' experiences of secondary care provision to influence the commissioning process and to ensure that complaints are used to drive up standards and facilitate improvements. The Francis Inquiry Report recommends that “GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services”.1 It also recommends that similar scrutiny and oversight takes place in relation to general practice complaints, and involves not only input from regulators such as the Care Quality Commission (CQC) but also from local Healthwatch and scrutiny committees. How confident are you that your practice is ready to both give and receive such scrutiny? Does complaint handling need to move up the practice agenda?
NHS complaints continued to rise during 2011-12, when over 3,000 complaints were received on average each week. Of the 162,100 complaints made, 54,000 written complaints related to GP practices and NHS dental services.3 There was also a rise in the complaints made to the medical and nursing regulators from the public as well as from employers. Complaints related chiefly to clinical treatment; for example:
- Delayed or wrong diagnosis.
- Omitted or delayed referral to a specialist.
- Failure to examine properly or investigate further when clinically indicated.
- Prescription errors, such as incorrect medication or incorrect dose of a correct medication.
Poor communication was also highlighted, particularly when insufficient information was provided about treatment; for example, potential side effects of medication. The way in which concerns were handled was also a cause for complaint, as was the manner of some clinicians who were perceived as ‘rude’ or ‘lacking in respect’.4
While most clinical complaints involve doctors, complaints and claims against practice nurses have risen in conjunction with their increased responsibilities. In seeking to reduce errors that give rise to complaints relating to clinical treatment, practices should be motivated by the desire to minimise risks to patient care and encourage practitioners to:
- Recognise the limits of their professional competency.
- Request a second opinion when in doubt about a diagnosis or treatment.
- Maintain appropriate skills and expertise.
The current NHS complaints procedure promotes the resolution of complaints at the earliest opportunity, known as 'local resolution'.5 Many informal concerns or verbal complaints can be addressed at the time they are made, and whenever possible staff should be encouraged to openly acknowledge when things have gone wrong and act speedily to put them right. Clinical and non-clinical staff should be confident about handling situations that are emotionally charged and allow a complainant the chance to explain their grievances.
Where no immediate response can be made the practice should follow the complaints procedures carefully and ensure that:
- Patients and their relatives or carers who make a complaint are appropriately supported and advised about advocacy or interpreting services when necessary.
- Complainants have an opportunity to clarify the issues through a face-to-face meeting or by telephone.
- Timescales for responding to the complaint are realistic and agreed with the complainant.
- Investigations are thorough, involving the staff concerned and, where appropriate, independent advice.
- Timescales are re-negotiated with the complainant if the necessary processes will take longer than anticipated; for example, if conciliation is indicated.6
- The outcomes of any investigation or review of the issues is shared with the complainant and where appropriate apologies are made, mistakes acknowledged, redress offered, and learning from the complaint is demonstrated through an action plan with clear timescales for any service improvements, including staff awareness raising or training.
Complainants who are not satisfied with the outcome
of the local resolution process are entitled to request a
review of their complaint by the Parliamentary and Health Services Ombudsman. All too often the ombudsman finds that deficient complaint handling by the organisation concerned has prevented an earlier resolution of the complaint (see Box 1).
Some practices appear to regard complaints negatively and respond by removing patients and their relatives from practice lists when they exercise their right to complain. The ombudsman's recent review of complaint handling shows that there was a further increase in complaints about unfair removal from practice lists despite specific focus on this issue in the ombudsman's previous report.7 Removal from a practice's list is also in the top ten complaints to The Patients Association.8
Poorly handled complaints can have unintended and far-reaching consequences for all concerned. Patients and their families, who may already be coping with ill health or bereavement, may experience additional stress and further strain to their relationship with the practice and the clinicians involved in their complaint. Equally, the stress suffered by individual clinicians can have adverse effects not only on themselves personally, but also on their interactions with other patients. Their clinical and diagnostic judgements can be compromised through loss of confidence, causing them to practise more defensively.9 The availability of professional and emotional support to staff can be as important as advocacy for complainants.
Occasionally, complaints are made that involve serious allegations against members of staff. As well as involving the practice partner who acts as the 'responsible person' in relation to the complaints process, external agencies such as the police and/or professional regulators may need to be contacted. Practice managers need to ensure that appropriate action is taken quickly in the interests of patient safety. Depending on the circumstances, the clinician involved may have to be suspended during an investigation into the allegations, or have restrictions placed on their work within the practice. A complaint may also highlight significant performance concerns or health problems in a member of staff, and the practice may benefit from external support and guidance.
In responding to the Francis Inquiry Report, the Health Services Ombudsman urged that “good complaint handling should be at the heart of the new NHS”.10 Her office promotes the following principles of good complaint handling and assesses patients' complaints against these criteria:
- Getting it right.
- Being customer focused.
- Being open and accountable.
- Acting fairly and proportionately.
- Putting things right.
- Seeking continuous improvement.11
Practices face increasing demands and risks during the current period of upheaval and change in the NHS. Responding positively to concerns and complaints is vital for the ongoing delivery of high quality patient care. Is good complaint handling a priority in your practice?
1. Robert Francis QC. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013.
2. Ward Platt A. Take careful steps to minimise risk in 2010. Management in Practice 2010;20:22-25.
3. Health and Social Care Information Centre. Data on Written Complaints in the NHS 2011-12. Available at: http://data.gov.uk/dataset/data-on-written-complaints-in-the-nhs-2011-12
4. General Medical Council. The state of medical education and practice in the UK, 2012. London: General Medical Council; 2012.
5. Statutory Instrument 2009 No. 309. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.
6. Ward Platt A. Conciliation in Healthcare: managing and resolving complaints and conflict. Oxford: Radcliffe Publishing; 2008.
7. Parliamentary and Health Services Ombudsman. Listening and Learning: The Ombudsman's review of complaint handling by the NHS in England 2011-12. London: The Stationery Office; 2012.
8. The Patients Association. Available at: www.patients-association.com
9. Cunningham W. The immediate and long-term impact on New Zealand doctors who receive patient complaints. NZ Med J. 2004;23;117:U972.
10. Parliamentary and Health Services Ombudsman. Francis Report Statement. Available at: www.ombudsman.org.uk
11. Parliamentary and Health Services Ombudsman. Principles of good complaint handling. Parliamentary and Health Services Ombudsman, 2009. Available at: www.ombudsman.org.uk