Anne Ward Platt
Management Consultancy Director
Anne (pictured) is director of a management consultancy specialising in conciliation, complaints and conflict management. She is the author of Conciliation in Healthcare: managing and resolving complaints and conflict. Anne has served as a nonexecutive director in the NHS for the past 10 years and she is currently the deputy chair of the Northumberland, Tyne and Wear NHS Trust.
NHS Complaints: Who cares? Who can make it better? This is the title of the report published by the Patients Association in September 2008, following a survey of members’ experiences of the NHS complaints procedure. In the foreword to the report, Claire Rayner, the Association’s President, calls for “a radical overhaul of a cumbersome failure”.(1)
The introduction in April 2009 of a unified complaints procedure for handling health and adult social care complaints is intended to herald a new approach to complaints handling.(2) The emphasis is on providing a personal, open and flexible response to complaints, focusing on outcomes, rather than a slavish and rigid adherence to processes.
The new legislation gives a general legal framework only, allowing flexibility and local variation to achieve the requirements of good complaints handling. However, an important change is that complainants now have the option of raising complaints in the first instance with their PCT, instead of with the provider organisation about which they are complaining.(3)
In an attempt to make the process more straightforward, speedier and less bureaucratic, the new arrangements comprise a two-stage framework only. The changes place particular emphasis on the importance of the first stage, Local Resolution. It is envisaged that the vast majority of complaints will be managed effectively at this stage. If the complainant is not satisfied with the outcome, they may request a review by the parliamentary and health service and/or local government ombudsman.
However, the Healthcare Commission, which handled second-stage healthcare complaints until April 2009, received up to 700 requests for independent review a month, and the parliamentary and health service ombudsman has made it clear that she does not expect her office to handle an equivalent volume under the new arrangements.(4,5)
Since the highest proportion of the unresolved complaints previously handled by the Healthcare Commission related to primary care, how can practice managers ensure that their practices are prepared for the introduction of the new procedures?
Key principles of complaints handling
Although there are procedural changes resulting from the new complaints system, the key principles of good complaints handling remain unaffected. The aim is to ensure wider recognition and application of these principles, so that best practice is demonstrated consistently in both health and social care organisations.
This has been the focus of the Early Adopter sites (EAs), which have been trialling the practices and tools needed to resolve the majority of complaints successfully at a local level.(6) And to assist public bodies within her jurisdiction, the parliamentary and health service ombudsman has previously published Principles of good administration and Principles for remedy. These form the basis for the ombudsman’s Principles of good complaint handling, and cover:
- Getting it right.
- Being customer focused.
- Being open and accountable.
- Acting fairly and proportionately.
- Putting things right.
- Seeking continuous improvement.(7)
In Scotland, there is already a direct route from Local Resolution to the ombudsman, and this system has been credited with the improvement in the number of complaints resolved at a local level. This is because the introduction of the two-stage process has been accompanied by:
- An emphasis on outcomes, not just processes.
- A shift in culture so that complaints are viewed positively, not defensively.
- Good governance arrangements to ensure that the new system is fully supported and integrated.
- Awareness that referral of a complaint to the ombudsman could potentially result in adverse publicity for the organisation concerned.
In undertaking your role as complaints manager, you will need to work with your practice colleagues to ensure everyone in the practice appreciates the importance of the new initiatives for complaints handling.
This is vital if you are to promote a culture that supports a timely and effective response to complaints and encourages service improvements and organisational learning as a direct result of them. Highly focused training and awareness raising is essential if staff are to feel confident about responding appropriately to concerns as and when they are raised.
Reception and administrative staff may find themselves receiving complaints about clinical staff or about organisational issues. Training in customer care should focus on responding appropriately to patients who are distressed or angry. This, together with training in complaints handling issues, should ensure that the first contact a patient has with the practice over their complaint is a positive experience.
Too often, a poor initial response can compound the problem, especially if the patient feels they have been met with a defensive or less-than-helpful attitude. The earlier concerns are addressed, the less likely it is that they will escalate to formal complaints.
The Healthcare Commission’s report on second-stage complaints, published in 2008, emphasised the need for improved complaints-handling systems in general practice as the top recommendation made in relation to GP complaints.(4) Good communication is a key component of effective complaints handling. This includes ensuring that:
- Written complaints are acknowledged promptly.
- Face-to-face meetings are offered and are conducted in a supportive, nonadversarial manner.
- Complainants are informed if the response to their complaint is likely to be delayed, and the reasons for this.
- The response addresses all aspects of the complaint and the explanations are jargon-free and easily understood.
- The complainant is informed when any agreed actions have been implemented as a result of the complaint.
In considering the practice culture towards complaints, managers should try to review their complaints literature through the eyes of a patient or newcomer to the practice. Look at your current complaints leaflet and ask yourself:
- Does the content of the information that you provide reflect the value your practice places on complaints?
- Is it user-friendly, and is the information available in other formats to meet special needs? For example, large type, Braille, audio CD, and languages other than English?
- Is it immediately obvious to whom patients should speak or write if they have concerns?
- Are the stages in the complaints procedure explained clearly?
- Is there reference to advocacy services, including contact details?
- Does it mention the role of conciliation?
The tone of your complaints leaflet, as well as its content, is important. People need to feel reassured that their future care will not be affected and that they will not be punished in some way if they make a complaint. This “fear of retribution or compromised care”, as well as a bureaucratic and lengthy complaints procedure, can deter people from complaining.(1)
Indeed, some of the respondents to the Patients Association survey were concerned that they would be removed from the practice list if they complained. And the process for removing patients from practice lists was an area highlighted by the Healthcare Commission as one of the top five complaints issues about GP services in their 2008 report on second-stage complaints.(3)
In trying to ensure that there are no obstacles that might prevent people from voicing their concerns, you should consider those groups for whom particular arrangements may be required. Do you, for example, have access to signing and interpreting services, specialist advocacy and material suitable for children or young people, and those with a learning difficulty or disability?
You may only need to access these resources very infrequently, and you may find that some or all of them are provided via your PCT. Being aware of the resources available, however, and knowing how to access them speedily, will ensure that you are able to respond effectively should the need arise.
In a previous article in Management in Practice magazine, I highlighted the importance of conciliation and its value as a resource for handling complaints in general practice.(9) The increased emphasis on resolving complaints at a local level should prompt managers to ensure that they are aware of the circumstances in which conciliation can be beneficial for all the parties concerned.
Independent conciliation can provide a process for facilitating:
- A better awareness of the issues involved in the complaint from the perspective of both the complainant and the person or organisation complained about.
- An opportunity for apologies to be offered, especially if mistakes have been made.
- Further, more focused explanations to be given, with input from an appropriate clinical adviser if necessary.
- Redress or remedy as appropriate.
- Evidence of service improvements or action to be taken as a direct result of the complaint.
As well as providing a supportive process for all the parties involved, conciliation can help to restore the relationship between the patient and the clinician, which may have deteriorated as a result of the complaint. The process can also be used proactively to prevent the type of breakdown in the clinical relationship, which may precede a formal complaint.
“Quick, efficient complaints system”
Patient complaints about GP services relate chiefly to:
- Clinical treatment.
- Attitude of GPs and other practice staff.
With respect to complaints involving clinical treatment, the Healthcare Commission’s 2008 report notes that some complainants were concerned that limited consultation time resulted in:
- Brief, poor-quality examinations.
- Inadequate explanations about treatment options.
- Insufficient, or no reference to potential side effects.
- Missed diagnoses.
- Late referrals to a specialist.(4)
Even when the GP’s clinical treatment or referral pathway were found to have been appropriate by the Healthcare Commission’s clinical advisers, there were concerns in some cases about the inadequacy of the explanations or information provided.
There was also evidence that where GPs were reluctant to engage positively with a complainant, this compromised a satisfactory outcome to the complaint at a local level. Practice managers need to be proactive to avoid situations where GPs fail to participate fully in addressing the complainant’s concerns.
The Patients Association report states: “The test for any organisation is that when they do get it wrong, a quick and efficient complaints system puts things right. That is the only approach to making things better. Above all, the system must fit the complainant, not the other way round.”(1) You should never underestimate the importance of:
- Listening carefully to a patient’s concerns.
- Offering a sincere apology.
- Providing explanations that are easily understood.
- Offering redress where appropriate.
- Showing that the practice has learnt from the complaint.
The role of the practice manager in relation to complaints is already vital and will become even more so if the number of complaints resolved at the earliest opportunity is to increase significantly. If the new procedures are to be more than cosmetic, they must be accompanied by a genuine commitment to respond constructively to complaints and to view them as positive drivers for change and valuable consumer feedback. Practice managers are in a key position to encourage the necessary cultural shift to meet this challenge.
1. Patients Association. NHS Complaints: Who cares? Who can make it better? Survey of members and their experience of the NHS Complaints System. Harrow: Patients Association; 2008.
2. Department of Health. Making Experiences Count: the proposed new arrangements for handling health and social complaints. Response to consultation. London: Department of Health; 2008.
3. HM Government. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (Statutory Instrument 2009 No. 309). London: The Stationery Office; 2009.
4. Healthcare Commission. Spotlight on complaints: a report on second-stage complaints about the NHS in England. Commission for Healthcare Audit and Inspection; 2008.
5. Parliamentary and Health Services Ombudsman. Remedy in the NHS: summaries of recent cases. London: The Stationery Office; 2008.
6. Department of Health. Making Experiences Count – reform of the Health and Social Care complaints arrangements. Available from:
http://www.dh.gov.uk/en/Managingyourorganisation/Legalandcontractual/Com… Accessed 4th November 2008
7. Parliamentary and Health Services Ombudsman. Principles of Good Complaint Handling. London: Parliamentary and Health Services Ombudsman; 2008.
8. October 2007, http://www.ombudsman.org.uk/improving_services/remedy/. Accessed October 2008.
9. Ward Platt A. Say you want a resolution: conciliation in general practice. Management in Practice 2008;14:24-26.