It is hard to view complaints positively. The word ‘complaint’ itself carries immediate negative connotations. Perhaps ‘adverse user feedback’ would be a better term? It is hard to view complaints as service improvement ‘jewels’, to be encouraged for the valuable insights that they provide. Nobody likes being complained about, and it is a natural response to become defensive. Self-confidence can take a hit and there is resulting personal stress.
Nurses, doctors and allied health professionals will no doubt see a fair share of complaints in their professional lives. As providers of essential services in a resource-constrained environment they will never be able to satisfy everyone that they treat. Healthcare delivery also relies heavily on human interaction, so some degree of error is inevitable. The best that we can try to do is to effectively manage risk and develop a proper patient safety culture. Effective complaint handling practices and procedures are an essential prerequisite to doing this. Active learning must also occur from complaints.
Sadly, history has not served NHS complaint handling well. For as long as I can remember, the NHS has been struggling to develop an effective NHS complaint handling system. There have been several reports over the years arguing for reform, but major problems stubbornly persist. Clwyd and Hart (2013:9), in their seminal report on NHS complaint handling, gave some essential historical context and a timeline to complaints reform.
Power imbalance
We can add to the long list the Francis report (2013). Chapter 3 of the first volume deals with complaints and in the conclusion the following telling statement highlights the inherent power imbalance between nurses, doctors and patients, which still urgently needs to be addressed—by having a proper and effective NHS complaints system, to feed into safety culture development.
‘It is clear that patients and their families can be reluctant to make or pursue a complaint, or even venture critical comment about care. A number of causes for this are possible including: A desire not to appear ungrateful for good care received; A wish to put a distressing experience behind them; Uncertainty about whether there was true cause for complaint; A fear of an adverse reaction from those criticised and their colleagues.’
Francis, 2013: 278
Reasons why patients complain
The clear message from the many reports is that patients often just want an explanation of what happened to them, an apology, and an assurance that lessons have been learnt. The driving force is not always monetary compensation, although it may be the only way practical way forward where patients' lives have been ruined or even lost by clinical negligence and litigation will have likely followed. Patients may have to adapt to living without a faculty or amenity, adjust their lives and encounter new financial care costs. They will need financial help with this, which compensation provides. Several reports on NHS complaints have catalogued what motivated patients to complain.
In my experience of writing about these issues, failures in communication often lie at the heart of many complaints and are also what can prompt patients to take matters further to litigation. I would strongly argue that if health professionals improved their communication practices with patients there would be fewer complaints and less litigation. Failures of communication between professionals themselves can also be seen to lie at the heart of many complaints. Failures to adopt good record-keeping practices can result in patient injury and even death.
Take, for example, some of the reasons identified by Clwyd and Hart (2013: 15):
- Lack of information—patients said they felt uninformed about their care and treatment
- Compassion—patients said they felt they had not been treated with the compassion they deserve
- Dignity and care—patients said they felt neglected and not listened to
- Staff attitudes—patients said they felt no one was in charge on the ward and the staff were too busy to care for them
- Resources—patients said there was a lack of basic supplies like extra blankets and pillows.
These can be seen to be very basic care issue failings. They lie at the heart of good care giving and are also issues that would equally apply to professionals in other disciplines. All professionals should maintain good levels of information giving, compassion, dignity, care, and attitude towards those who are relying on them. It is how we demonstrate our individual professionalism.
Transparency in the process
A failing highlighted by Francis was the way the Trust in question dealt with complaints:
‘It was a feature of complaints handling at the Trust that complainants were met with formulaic apologies, assurances that lessons had been learned and action plans which did not prevent repeated deficiencies of a similar nature.’
Francis, 2013:283
I would argue, from reading more recent reports, that this problem persists in some trusts. In its report Shifting the Mindset, Healthwatch (2020) showed the level of progress made and concerns were expressed. Sir Robert Francis, the chair of the Mid Staffordshire Public Inquiry (Francis, 2013) is also the Chair of Healthwatch and commented in the foreword that the NHS needs to do better in showing how complaints are used. The report found several major failings with the NHS complaints system, including:
- Local reporting on complaints is inconsistent and inaccessible
- Staff are not empowered to communicate with the public on complaints
- Reporting focuses on counting complaints, not demonstrating learning
- Only 38% of trusts make public any information on the changes they have made in response to complaints. (Healthwatch, 2020: 5)
New reports
Most recently the reports by Baroness Cumberlege (2020) and Donna Ockenden (2022) have again put NHS complaint handling into the spotlight.
The report of the Independent Medicines and Medical Devices Safety Review took a deep dive into NHS patient safety and care practices and found the system seriously failing patients in several key areas (Cumberlege, 2020). The review was asked to explore issues relating to Primodos (a hormone-based pregnancy test), sodium valproate and pelvic mesh. Patient complaint handling was one of several important over-arching themes addressed in the report under the heading, ‘We do not know who to complain to’. Some headline findings were:
‘Many of those affected by the interventions under review have expressed their frustration at the lack of a clear pathway for them to make a complaint or raise concerns about aspects of their care.’ ‘Dissatisfaction with how the system has responded to complaints, sometimes multiple, about named clinicians and individual Trusts has been a common thread throughout our engagement with those affected.’ ‘Complaints do not appear to be a priority; the NHS-wide Complaints Standards Framework for complaint handlers has been under development for years.
Again, these findings on patient confusion and dissatisfaction with the complaints system are not new. The NHS does not appear to be able to get its complaint system working properly at various levels.
Moving on to the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust (the Ockenden report) (2022), one eye-catching news headline ran:
‘Catastrophic failures at an NHS trust may have led to the deaths of more than 200 babies, nine mothers and left other infants with life-changing injuries.’
The report itself discusses lack of openness and transparency and contains important patient safety lessons for all nurses and doctors in all NHS care areas.
‘There is evidence that complaint responses lacked transparency and honesty, especially with regards to clinical care. The review team has identified families where care was sub-optimal, where different management would likely have made a difference to the outcome, however the complaint responses justified actions, delays, and omissions in care. In addition, they often lacked compassion and in a number of responses it was implied that the woman herself was to blame.’
The information is out there
It is clear that some trusts demonstrate very good complaints processes but the poor practices identified in some trusts do tend to eclipse those. There is a lot of good complaints policy information and guidance produced by several NHS stakeholders and organisations such as the Parliamentary and Health Service Ombudsman (PHSO). There are the NHS Complaint Standards, currently being piloted (https://tinyurl.com/4rmxr7fm).
Key information on good practice in NHS complaint handling has been available for many years, yet we still have national patient safety tragedies where patient complaint handling features strongly as a critical safety failing. This raises again the issue of how some sections of the NHS are demonstrably unable to learn the patient safety lessons coming from past adverse events. They have not sufficiently analysed reasons for and outcomes of complaints and have not properly communicated with patients over this.
Conclusion
We have seen that history has not served the NHS well when it comes to the handling of patient complaints. Sadly, there are too many instances of failure in this area. The reports mentioned here, and others, have all given key recommendations and identified common problems but all this wisdom has not permeated sufficiently down into the structures of the NHS. The reports often recount the same problems, give the same solutions, and make the same clarion calls for change.
The systemic issues identified in past reports may sadly be viewed as being intractable as they have gone on for so long. The seemingly prolonged deafness of some sections of the NHS to calls for change is unforgivable. Unfortunately, I fear that future reports will also be saying the same thing about complaints as the NHS does not presently have a sufficiently robust patient safety culture and complaints system.