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Say you want a resolution: conciliation in general practice

28 August 2008

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Anne Ward Platt

Management Consultancy Director

Anne is director of a management consultancy specialising in conciliation, complaints and conflict management. She is also the deputy chairman of Northumberland, Tyne and Wear NHS Trust. Anne is the author of Conciliation in Healthcare, written in response to requests from healthcare staff for clear and accessible information and guidance about conciliation

Around 140,000 complaints are made annually about NHS treatment and care. Some 10,000 unresolved complaints are referred to the Healthcare Commission for an independent review, and of these, a quarter are returned to the healthcare organisation concerned for further action to be taken at a local level. The highest proportion of the unresolved complaints – about 3,700 – relate to the primary care sector and include those about GPs and dentists.(1)

These figures are contained in the Healthcare Commission’s report Spotlight on Complaints,(1) published in 2008, which focuses on the need for improved complaints handling and the recognition that complaints can drive service improvement. A key message in the report is that in a significant number of cases there was insufficient awareness, at a local level, of how the complaint could have been handled more effectively.

Practice managers can significantly influence the effectiveness of complaints handling in their organisations if they have a clear understanding of the range of options available, particularly in difficult or complex cases. This should include an awareness and understanding of the role of conciliation.

About conciliation
Conciliation is a dispute resolution process that is used in relation to NHS complaints, and is widely recognised as an effective means of achieving an outcome that is satisfactory for all the parties concerned.(2,3) It involves using an independent person, the “conciliator”, who acts as an inter­mediary between the complainant and the person against whom the complaint has been made or, in the case of an organisation, its representatives.

The process aims to facilitate an agreement between the parties by enabling them to understand each other’s positions and to gain insight into the circumstances which gave rise to the complaint but which may not at first have been apparent. Separate meetings take place between the conciliator and the individual(s) concerned, often in a neutral venue, and where appropriate the parties are brought together for a joint meeting.

The period of time required for the conciliation process will vary according to the issues involved, as well as other factors such as the health of the complainant or the patient whose care is at the centre of the complaint. The speed with which resolution can be effected will also depend on the extent to which the positions of the parties have become entrenched.

However, some complaints may be resolved very speedily once the conciliator has been able to highlight the misunderstandings that have arisen, or has enabled the parties to appreciate each other’s points of view. Complaints may even be resolved by telephone without the parties meeting at all with the conciliator.

Conciliation may be offered by a primary care trust (PCT) in situations where the complainant remains dissatisfied with a practice’s response to the complaint, or where the complainant has chosen to make their initial approach about the complaint to the PCT rather than to the practice.

Sometimes, the clinician or practice manager involved in handling the complaint will suggest to the complainant that conciliation may be a helpful way forward. This is more likely to occur in practices that either have previous experience of conciliation or an awareness of its potential benefits. For this reason, it is helpful if reference is made to conciliation, not only in information prepared for patients or complainants, but also as an integral part of staff training in complaints handling.

Deciding upon conciliation
Conciliation can be used proactively. In some situations, the use of an independent intermediary, skilled in healthcare conciliation, can help restore deteriorating clinical relationships, either with the patient or with their relatives or carers. This can be vital where the ongoing treatment and care of a patient is at risk as a result of a breakdown in clinical engagement.

Conciliation can also be used to address staff grievances, or where working relationships among practice staff give cause for concern as a result of certain kinds of behaviour. If issues are not addressed effectively, situations can escalate and present a threat to patient care as well as affecting the working environment of the individuals directly involved.

Where conciliation is proposed, for whatever reason, the parties concerned should have access to information about the process and what it entails. Complainants should also be made aware of the appropriate advocacy and support available. Practices will find it useful if they maintain a checklist of the issues that need to be considered in relation to the conciliation process, as well as up-to-date information of relevant contacts locally. These could include details of conciliators who specialise in healthcare conciliation, or PCT contacts who should be able to suggest appropriate conciliators.

It is also useful to keep a note of neutral venues for meetings. These may be more appropriate, particularly in highly charged situations, when it may be advisable to avoid the practice setting. In some instances, PCT premises are used for this purpose, although on other occasions it may be best to avoid any connection with a healthcare organisation at all.

Details of appropriate support for complainants should also include contacts for interpreters whose involvement may be essential in some conciliations to assist those complainants for whom English is not their first language.

Things to consider
In addition to the above, some points to bear in mind about conciliation are that:

  • It is a voluntary process, and the parties can withdraw at any time.
  • It is a confidential process, and conciliators need to comply with the relevant NHS guidance.(4,5)
  • It can be used in relation to complex clinical complaints as well as complaints involving the attitude and manner of healthcare staff or environmental or organisational issues.
  • Appropriate consent must be obtained – for example, regarding access to health records with respect to clinical complaints, or other relevant documentation relating to the issues.
  • It is not essential for the parties involved in the complaint to meet together during the conciliation process unless a desired outcome is a restoration of the relationship between them.

This last point is particularly relevant in certain situations where patients may not wish to meet with the healthcare professional concerned – for example, where a complaint has been made by someone who is no longer being treated by that health professional or has moved to another practice. This may include situations where complaints are made following the removal of a patient from the practice list.

Other situations where the complainant may not wish to meet with, for example, the GP concerned include those occasions where the complaint is made by a patient’s relative, possibly following an adverse event or bereavement. In these circumstances, maintaining the relationship between the GP and the complainant may not be pertinent to the resolution of the complaint.

Communication problems
The Healthcare Commission’s report also raised the issue of poor communication across all clinical areas.(1) For example, clinicians sometimes failed to give adequate and clear information about their treatment to patients, or where appropriate to the patient’s relatives or carers. This was a common problem in relation to complaints involving GPs.

Some GPs neglected to give information about the potential side-effects of certain treatments because they believed that the information would be too detailed or complex for a layperson to understand. The Healthcare Commission’s advisers observed this in many of the cases they reviewed. They also highlighted the extent to which GPs omitted to engage positively with complainants and emphasised the need to offer face-to-face meetings.

Sometimes the language used in written responses to complaints is difficult for complainants to understand; for example, where medical or technical jargon is used, or references are made to procedures without putting them into context. Conciliation can provide an opportunity for explanations to be made in the most appropriate way to suit the needs of the individual complainant.

Poor communication or an inability to engage with the complainant can prevent an early resolution of complaints even in situations where the clinician may have acted correctly. In such circumstances, an independent clinical adviser/expert can be involved in the conciliation process to great effect.

Complainants often appreciate the input of an independent clinician who may be asked to provide a written report and/or attend a meeting, facilitated by the conciliator, to discuss the clinical aspects of the complaint. As well as providing explanations for medical terminology, an adviser will also be able to provide detailed information about the relevant condition or treatment if required.

It is not uncommon for a complaint to cover a number of separate issues, including the way in which it was handled in the first instance. Staff responding to a complaint can exacerbate the situation if they are insensitive or offhand.

Practice managers can find themselves involved in the conciliation process if issues are highlighted about the behaviour of receptionists or regarding inadequate administrative procedures – for example, failure to record or pass on telephone messages. Receptionists acting in a “gatekeeping” role can antagonise complainants if they appear to be preventing access to the GP. Such issues may indicate the need for customer care training or improvements to be made to existing protocols or policies.

Towards resolution
Complaints often originate from situations that are distressing for all concerned. Where these occur following the death of a patient, an adverse event, a side-effect or reaction arising from clinical treatment, or where mistakes have been made, conciliation offers an opportunity for the issues to be addressed in a way that is supportive for both the complainant and the clinician. The process can enable more effective communication between the parties, which may in turn facilitate resolution of the complaint.

Possible outcomes may include any or all of the following:

  • Apologies or other appropriate forms of redress, especially when mistakes have been made.
  • Clear explanations about the issues, using an independent clinical adviser when necessary.
  • Plans to highlight what improvements or actions can be taken as a direct result of the complaint.

It is vital that where actions are agreed as a result of the conciliation process, these are implemented. Where practice managers have this responsibility they should ensure that complainants are kept informed of progress, particularly where organisational or service improvements cannot be carried out immediately.

Conciliation can provide a supportive process for staff as well as for those making a complaint. Complaints can have a deleterious effect on a health professional’s clinical practice, particularly if they are engaged in a long and protracted complaints process. This can be at best an inconvenience but at worst an extremely distressing experience.

All the parties concerned benefit from a process that enables effective communication of the issues, an opportunity for understanding each other’s points of view, and an outcome that provides potential for individual redress and service improvement. The advantages of conciliation should ensure that it is viewed as a valuable resource by practices intent on raising their standards of complaints handling or of addressing deteriorating clinical or workplace relationships.

1. Healthcare Commission. Spotlight on complaints: a report on second-stage complaints about the NHS in England. London: Commission for Healthcare Audit and Inspection; 2008.
2. Statutory Instrument 2004 No. 1768. The National Health Service (Complaints) Regulations 2004. London: TSO; 2004.
3. Statutory Instrument 2006 No. 2084. The National Health Service (Complaints) Amendment Regulations 2006. London: TSO; 2006.
4. Department of Health. Confidentiality: NHS code of practice. London: DH; 2003.
5. Department of Health. Guidance to support implementation of the National Health Service (Complaints) Regulations. London: DH; 2004.