Complaints are, in most of the trusts that I have worked in, recognised as an important area of insight for quality improvement and learning. They are rich in representing the lens of the patient and/or their family, identifying issues that would not typically be picked up in internal monitoring systems.
The NHS receives more than 200 000 formal complaints each year. Failures to detect and respond to complaints that report harm and negligence have been illustrated across a range of high-profile public inquiries. Van Dael et al (2022) noted that, in acknowledgement of these failures, several reforms were introduced to improve learning from complaints, such as the regulatory requirements for hospitals to formally investigate and collect data from complaints. Yet, as the most recent inquiry at the Shrewsbury and Telford Hospital NHS Trust has unfolded, van Dael et al (2022) reflected that there appears to have been limited system-wide progress.
As the executive with delegated accountability to quality assure all responses to complaints prepared by my Trust, I try to review many of the concerns in real time as they come in, but there are many I do not. For those I do see, if they relate to a concern I think can be dealt with rapidly and informally, I will action these with relevant colleagues. However, this is not appropriate for all complaints and most will progress via the NHS complaints process.
Many of us would agree that the ability to meet with individuals or their families who have made a complaint often brings an outcome that addresses all areas, but this is not practical at scale. Although many of us take a lot of time ensuring that written complaint responses answer all concerns with candour and compassion, an earlier van Dael et al study (2020) showed that, critically, most patients and families who submit complaints want to prevent harm from occurring to others, but are often left dissatisfied.
Concept versus practice
I question, therefore, to what extent the current NHS complaints process is fit for purpose. Which is why I was interested to read the latest research study by van Dael et al (2022), which sought to examine how national policies are applied in practice and whether there are any discrepancies between policies as intended and the reality of how they are introduced in local practice. The study findings illustrated four areas of practice where national policies and regulations can have adverse consequences locally, and could undermine an improvement-focused approach to complaints.
Access
A key finding was that there are muddled routes to raise concerns, with both staff and patients being confused about the difference between the Patient Advice and Liaison Service (PALS) and a formal complaint department.
Investigation
Van Dael et al found that, typically, formal investigative procedures were predominantly structured to judge the ‘well-foundedness’ of complaints. The legitimacy of complaints was typically appraised by investigators who cross-validated the issues raised using corresponding hospital documentation and staff statements, with internal evidence regarded as superior.
National data collection systems can create ‘false information’
Although there is a national data collection system (named KO41a), van Dael et al considered that it is insufficiently granular for actionable learning.
Performance targets, adverse incentives and workarounds
This is an area that I have reflected on the most. The study found that the senior staff who were concerned with monitoring complaints often focused primarily on national performance targets for complaints handling, which are typically related to the number of complaints and the timescales taken for responses to be sent. These targets to handle complaints predominantly focus on administrative aspects, missing the level of risk of not getting the right response to patients and their families. This last point resonated with me because I know that across many trusts there are unacceptable delays in complainants receiving a response.
Culture change
The van Dael et al (2022) study demonstrates how national policies and regulations for complaint handling can take away, rather than promote, quality improvement in local settings. The study team makes useful recommendations that I will be reviewing locally, alongside proposals for ‘several necessary reforms’, the most powerful of which for me is how we involve patients in complaints investigations.
Developing our approach to and culture of how we receive and respond to complaints presents the opportunity to undertake more meaningful data analysis strategies to uncover and address systemic causes behind recurring complaints, and to prioritise quality improvement interventions.