Sadly, the NHS has never been able to get its complaint system right, even after decades of trying. The Parliamentary and Health Service Ombudsman (PHSO) (2020) has produced a report on complaint handling with a focus on the NHS. It spells out clearly the problems, challenges and opportunities to put things right. It is, however, another good report on NHS complaint handling in a long line of such—will this one will succeed where the others failed? The problems that beset NHS patient safety policies and strategies that I have regularly covered in my columns apply equally to NHS complaint handling—failures in leadership, a focus on financial rather than patient safety priorities, poor education and training in investigative techniques and management, and so on.
A steady flow of reform reports
There is a long history of NHS reports into how complaints are handled and what needs to be done to make things better, but progress in effecting change has been slow. Clwyd and Hart (2013) in their seminal report gave a timeline of past reports, and how the problems have persisted since the mid-1990s. NHS complaints were also discussed in the Mid Staffordshire inquiry, which found that although there were many individual complaints providing ‘graphic proof that something was seriously wrong at the Trust’, the system they ended up in ‘failed to draw the necessary alarm signals from them, let alone the relevant lessons' (Francis, 2013: 245–246).
In 2003 the Department of Health (DH) identified several problems with the NHS complaints system, many of which are still with us today. More often:
Making Complaints Count
The problems are unpacked further in the PHSO (2020) report, which found a broad consensus that there is a need to reform the complaints system. Section 1 discusses promoting a learning and improvement culture under several headings.
Leadership
The importance of leadership from the top and the promotion of learning and improvement is a key aspect of the reform agenda. Again, this is far from a new finding.
‘The staff we spoke to during our research illustrated that leaders in some organisations do not sufficiently value complaints and feedback.’
Defensiveness
The report identifies an ongoing culture of defensiveness when handling complaints. This is a seemingly intractable systemic problem, and can also be seen when it comes down to the reporting of adverse health events in a patient safety context. In one sense it is quite easy to understand why the problem exists. It is a question of human nature; nobody likes to be complained about and our instinctive reaction is self-protection. To become defensive until matters become clearer. Add to this the well-chronicled tendency in the NHS to maintain a blame culture when things go wrong, and staff will be reluctant to own up to a mistake.
The PHSO report goes into some detail on the aspect of promoting a learning and improvement culture. This real-time analysis of issues in a practical, work-related context is one of the key strengths of the report. Issues are not considered in the abstract and some interesting findings are revealed from the research evidence:
Mislabeling
‘Several advocacy providers reported that some NHS organisations were mislabeling “complaints” as “concerns”, and not prioritizing equally.’
‘We also heard that complaints teams are not always given sufficient respect, authority or “gravitas” from their colleagues compared to other teams.’
Adequate resources
Staff are not always getting protected time to investigate complaints properly. Complaints are, in some cases, an add-on to a person's other responsibilities. Concerns are also expressed that complaints teams are not appropriately resourced. The need to treat staff who are being complained about with empathy and sensitivity is also an issue discussed. So often in policy reports and documents the focus is on the complainant and the person being complained about is forgotten.
Insight and learning
The report also deals with NHS organisations reporting on insight and learning from complaints. Historically, we know that this has been poor. Evidence received by the PHSO shows that NHS organisations are not sufficiently publicising the insight they have taken from complaints.
Positively seeking feedback
The second section of the report concerns positively seeking feedback. The point is made that when organisations proactively seek feedback from service users and resolve concerns promptly this can prevent matters spiraling into a protracted complaints process. In my past reading in this area I have been impressed by the concept expressed in many places that the goal should be to turn the complainant into an advocate for the organisation. This should be the gold standard for all to aim for. The report found evidence that organisations are missing opportunities to proactively seek feedback and resolve concerns. Stronger processes are needed, but resource constraints are one barrier to earlier resolution.
A more personalised approach
Trusts adopting an approach to complaint resolution that benefits both staff and complainants is also discussed:
‘By conducting face-to-face “early intervention” meetings in response to formal complaints or other concerns raised, the Trust can provide a more personalized experience for people who use services. It avoids what can be a long and frustrating process of communication by letter.’
Other issues include providing multiple channels for feedback and ensuring people have access to independent advice.
Thorough and fair
Section three of the report discusses the components of an effective complaint system. Complaints should be resolved through an open, transparent and responsive process. This should enable complaints to be examined thoroughly and in a timely, proportionate manner. Complaint handling staff should be properly trained and all parties including the staff involved should be kept up-to-date on what is happening with the complaint.
Avoiding delays
Delays in responding to complaints was the most common theme found in the review of investigation reports:
‘Most notably, it featured in 53% of the 178 we reviewed involving one NHS organisation, and in 41% of the 56 reports we reviewed involving organisations across the NHS and social care.’
Poor handling of investigations into complaints contributed to delays. Clear standards around timelines for investigating complaints would help in resolving complaints more quickly. Ensuring a coordinated response to complaints was also discussed—complaints involving multiple organisations across the NHS and social care are not always that well co-ordinated. The causes of poor co-ordination include organisations lacking a shared understanding or appreciation of the need to work together, and inconsistent approaches to how NHS organisations respond to complaints.
Fair and accountable
Section 4 highlights the importance of giving people fair and accountable decisions:
‘When things do go wrong, it is important that organisations encourage staff to identify suitable ways to put things right for those raising feedback and complaints. This should always include providing meaningful apologies and showing why learning can be taken from the complaint.’
If such reasonable, meaningful apologies are not given or the process of communicating with the complainant is poor, litigation could result—as previous research revealed:
‘Themes emerging from the interviews identified that staff reactions fell below the standards expected. Explanations or apologies were deemed to be rare or insufficient when they were given. Several interviewees remarked that, had these initial processes been handled better, they may not have pursued their claim.’
A unified vision
Section 5 discusses a unified vision for good complaint handling. A Complaints Standard Framework is introduced (https://tinyurl.com/y4yayb5g) to provide consistency. The public consultation on this draft framework is open until 18 September 2020 (https://www.ombudsman.org.uk/csf).
The report concludes with several issues for Parliament to consider, including the reform of existing legislation on complaint handling in the NHS.
Conclusion
It would be good to see this report defy the pattern of previous attempts and to lead to positive and sustainable changes. The Complaints Standard Framework is an encouraging development and the findings here deserve wide dissemination and support. The nagging doubt is that we have all been here before, many times. Changing the NHS complaints is a herculean task and in a COVID-19 focused care environment it is questionable whether there is a government or NHS appetite for root and branch complaint system reform. There are other arguably more pressing matters to contend with. Hopefully, though, the nettle of NHS complaints reform will soon be grasped.