Nobody likes complaints being made against them; it is a fact of human nature that the person who is subject to the complaint will feel hurt, defensive and will probably suffer a loss of self-esteem and self-confidence. The complainant may well have felt that it was the only way to move forward in a difficult situation where they felt confused, isolated and afraid because they did not understand what was happening to them or a relative. Nurses or doctors may have failed to explain properly what may be a simple matter because they are so busy. The patient then resorted to making a formal complaint in order to get information that should have been given before. It should not be forgotten that there are always two sides to any complaints story. There are no winners, and nor should there be. Both sides will bear a heavy emotional cost. We need to do all we can to avoid complaints being made in the first place.
No winners in NHS complaints
History has not served the NHS complaints system well. There have been many reports about NHS complaints going back to 1994 and the Wilson report, Being Heard, saying the same or similar things about the system. Many have argued and continue to argue that the NHS complaints system needs to be more responsive, simpler in operation and less defensive. It is fair comment to argue today that the NHS complaints system is still plagued with endemic and systemic problems. You would have been hard pressed to have made a more complicated NHS complaints system than the original one and some improvements have been made but the system is far from being fit for purpose in my view.
Considering the context
A recent report from Healthwatch (2020), Shifting the Mindset, identifies some major problems with NHS hospital complaint handling and makes several key recommendations for change. It's important to give some essential context to the discussion and to identify some basic underlying themes.
First, there is an imbalance in the power relationship between a nurse or doctor and patient. The health professional is always going to be the most powerful person in the healthcare equation. Patients are out of their usual environment or comfort zone, often thinking the worst about their condition. They know they lack the professional knowledge they so urgently seek. The nurse and doctor are the gatekeepers to this specialist knowledge and although to them the patient may be the fourth patient of a normally very busy morning clinic, to the patient, it is perhaps the most worrying and important day of their lives. The NHS governance system always needs to take account of this inherent power imbalance and to compensate for it in its systems, particularly the complaints system.
Second, the defensive NHS culture when it comes to adverse health events is well chronicled:
‘There seems to be a prevailing attitude of defensiveness in the NHS when things go wrong, and a reluctance to admit mistakes, which is likely to be leading to more clinical negligence claims.’
The Behavioural Insights Team (2018) in association with NHS Resolution found in a complaints survey that the majority of those surveyed (69–75%) rated the response to their complaint as ‘poor’ or ‘very poor’ in terms of accuracy, empathy, speed of response and the detail they received.
The report also highlighted interview findings that there was a general dissatisfaction with the complaints process.
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The Healthwatch view
Healthwatch is the independent national consumer champion for people who use health and social care services. It also provides a leadership and support role for the local Healthwatch network. The present Chair of Healthwatch England is Sir Robert Francis QC, who chaired the Mid Staffordshire inquiries. For Shifting the Mindset Healthwatch investigated how hospitals report on complaints and whether current efforts are enough to build public trust (Healthwatch, 2020). Unfortunately, the findings are not good, and hospitals need to do much more to improve matters.
For the report, Healthwatch searched the websites of 149 NHS acute trusts in England and looked for substantive reporting on complaints. Researchers also looked for reporting of data on informal complaints and concerns handled by the hospital's Patient Advice and Liaison Service (PALS) team. A 0-3 rating was then given to each trust for the level of transparency shown in its reporting and the quality of learning that it has evidenced from the documentation shown.
Local reporting on complaints is inconsistent and inaccessible
According to Healthwatch, all hospital trusts are reporting to NHS Digital on the numbers of complaints they receive, but only a minority report any more meaningful data at a local level. Analysis showed that just 1 in 8 hospital trusts (12%) are demonstrating that they are compliant with the statutory regulations when it comes to reporting on complaints. Of the 104 trusts that included information on complaints in their annual report, only 39 included the total number of complaints received and/or referred to the Parliamentary and Health Service Ombudsman (PHSO), with little or no further detail. This means that only 65 trusts (44%) included any meaningful information about the types of complaints that they had received, and how they dealt with them:
‘Fewer than two trusts in 10 met our expectations for a high level of transparency in reporting on complaints. Most trusts make only the bare minimum information available.’
All hospitals must produce an annual statutory complaints report but they are only required to make it available to those who make a request for it. The report found that hospital complaints staff were often not aware of the reports or who could access them.
Reporting focuses on counting complaints, not demonstrating learning
‘ Only 38% of trusts make public any information on the changes they've made in response to complaints Much of this reporting is still only high-level, telling us little detail about what has changed and only stating that “improvements were made”.’
The report found a tendency in many complaint reports to herald the fact the low numbers of complaints indicate that the trust is doing well in terms of health quality and engagement. This may be a mistaken assumption:
‘A higher number of complaints does not necessarily mean that the quality of care is worsening. It could mean that people are more informed about how to complain and more confident that speaking up will make a difference.’
A story to tell
Patients who complain and the general public need to have confidence and trust in the complaints system and that is only built up gradually over time. Many patients who complain don't want compensation, they want an explanation of what occurred, an apology and an assurance what happened to them will not happen to anybody else—that lessons have been learnt and effective changes made.
In my view, and as shown in several Care Quality Commission (CQC) reports, trusts are bad at sharing lessons of past adverse events and telling the public and other trusts what learning has taken place. This gross system defect is not helping build public confidence in the NHS complaints system. The only conclusion that can be reasonably drawn from it is that patients and the public will feel that complaining makes no difference. This links into the CQC's ‘Declare Your Care campaign (www.cqc.org.uk/DeclareYourCare). The CQC points out that people regret not raising concerns about their care, but those who do raise concerns see improvements:
‘One reason for not raising concerns is the feeling that nothing would change as a result (37%).’
If more trusts publish more meaningful and detailed statements on their complaint learning, then hopefully more people will speak up about the care that they received and confidence and trust in the system will be demonstrated. The Healthwatch (2020) report does highlight some positive examples of trusts demonstrating learning. It is not all doom and gloom, but it is clear trusts should be doing more to instil public confidence in the complaints system. The main approach adopted when it comes to annual reports seems very perfunctory and generally not much is given away. It seems to me as if the complaints are treated as an embarrassment and the least said on them the better. I would agree with this statement in the report's recommendation section:
‘Feedback from patients should be seen as an opportunity to learn and demonstrate improvement rather than an adversarial process to be managed and minimised.’
Conclusion
The NHS has a long and unsettled history with how it deals with NHS complaints. The current system echoes many problems of the past and I would say it is still far from being satisfactory. Developing an ingrained patient safety culture—which is itself a long way off—should also bring about sustainable positive changes in the quality of NHS patient complaint handling and feedback. Shifting the Mindset is an excellent report that provides a window and perspective on how well NHS hospital trusts across England communicate what they are doing on complaints and whether this is instilling patient trust into the system. The answer from the survey results appears to be not that well and that much more could be done.