Nobody likes being the subject of a complaint. It can cause distress, anxiety, loss of self-esteem and confidence. Human nature leads us to becoming more defensive. All this is compounded when the healthcare environment you practise in manifests a blame culture and then things go from bad to worse. We have seen recently the concerns expressed by Andrea Sutcliffe, Head of the Nursing and Midwifery Council (NMC), via Lintern (2021):
‘Some employers were referring nurses without any investigation at all, while half of initial enquiries to the NMC were rejected or required further work. She told The Independent this emphasis on blaming the individual meant underlying causes of safety errors were being missed and so they were likely to be repeated.’
As well as inhibiting the development of an effective NHS patient safety culture in relation to avoiding errors in healthcare delivery, this trend will also cause serious damage to how patient complaints are dealt with. A blame-ridden working environment does not foster the development of a just learning culture and can inhibit people owning up to and reporting errors.
The Parliamentary and Health Service Ombudsman (PHSO) has recently published several documents relating to NHS complaint handling. The NHS Complaint Standards sets out how organisations providing NHS services should approach complaint handling (PHSO, 2021a). These standards will apply to NHS organisations in England and independent healthcare providers who deliver NHS-funded care. They are being tested in pilot sites in 2021 and will be refined and introduced across the NHS in 2022. Also published is a model complaint handling procedure (PHSO, 2021b) although technically this is a draft for information and not live guidance. It will be tested with organisations who have agreed to pilot the new Complaint Standards, as will a new set of modules giving guidance on handling complaints (PHSO, 2021c).
NHS Complaint Standards
There is a single vision set out for staff and NHS service users (and the people who support them) of what is expected when a complaint is raised:
‘This will help make sure everyone experiences a culture that seeks out learning from complaints, and meets the outcomes set out in My Expectations. The Standards are the first step towards recognising complaint handling as a professional skill. They will set a clear path for all services to harness the rich learning that comes from feedback and complaints to help improve services for the benefit of all.’
This goes into detail on the standards, dealing with such matters as why they are needed, benefits and definitions. The standards are:
- Welcoming complaints in a positive way
- Being thorough and fair when looking into complaints
- Giving fair and accountable responses.
- Promoting a just and learning culture (PHSO, 2021a: 11).
The draft complaint handling guidance (PHSO, 2021c) contains several modules including:
- Promoting a just and learning culture
- Making sure people know how to complain
- Identifying a complaint
- Early resolution
- A closer look—clarifying the complaint and explaining the process.
There are 13 modules in total and in each there is a detailed discussion of relevant issues covering several pages.
Implantation challenges ahead
All these materials provide excellent guidance on NHS complaint handling. They have the potential to make demonstrably good and sustainable change in a vexed area of NHS practice. There is, however, a lot of material here to digest. The module, ‘Who can make a complaint—consent and confidentiality’ is 22 pages in length. ‘Making sure people know how to complain and where to get support’ comes in at 14 pages. The module material is excellent, but I do wonder: how will all the material produced for the NHS standards be effectively developed, distilled and implemented in a very busy NHS that is also dealing with the COVID-19 pandemic? The reports of the pilot schemes will help in this regard and will give information in due course on implementation and reception; bearing in mind also that the pilot sites will have been very busy having to deal with COVID-19.
In considering the issue of patient safety and health quality information overload in a busy NHS, the seminal Care Quality Commission (CQC) report, Opening the door to change, had this salutary message, which should always be borne in mind when drafting and developing policies and procedures:
‘Trusts receive too many safety-related messages from too many different sources. The trusts we spoke to said there needed to be better communication and coordination between national bodies, and greater clarity around the roles of the various organisations that send these messages.’
Difficulties are now even more pronounced with the COVID-19 pandemic and the demands on NHS staff. Shorter, more condensed NHS complaints advice may now be more readily received and acted upon. As the adage goes, less can be more.
A feeling of déjà vu
In reading the PHSO documents a great feeling of déjà vu comes over the reader. The NHS has been trying to get a fit-for-purpose complaints system for at least 28 years and it has still not succeeded.
‘The NHS Complaints Procedure was set up in response to “Being Heard”. This followed the report of a review committee, which had been chaired by Professor Alan Wilson in 1993. Its purpose had been to review how complaints were dealt with in the face of growing criticism of outdated procedures.’
One of the perpetual and intractable problems has been getting the NHS complaint system right, along with developing a patient safety culture and learning from past healthcare errors. History has not served the NHS well here despite countless reports, often saying the same things and pointing to the same issues. Clwyd and Hart (2013) produced a detailed analysis of NHS complaint handling, following the Mid Staffordshire crisis where complaint handling was heavily criticised. In chapter four they discussed what it feels like to complain. Around 400 people contacted the review to share their experiences of complaining, how it felt in practice and what they went through. Chapter four explored themes from this evidence. These included ‘information and accessibility’, and ‘freedom from fear’:
‘Some people told us that they were unaware how to raise concerns or make complaints, either for themselves or on behalf of friends or relatives. It was clear that many had wanted to complain but did not…’
‘People expressed their fear that their, or their relative's, care might get worse if they were to complain. They also felt intimidated by the power of professionals or institutions; the complexity of the system and the feeling that nothing will happen—that all their effort will prove to be worth nothing.
Other themes related to issues of sensitivity, responsiveness, a prompt and clear process, a seamless service, support, effectiveness and greater independence when there are serious care failings. Key recommendations included the need for ‘appropriate professional behaviour’ in the handling of complaints, including ‘honesty and openness and a willingness to listen to the complainant, and to understand and work with the patient to rectify the problem’. Another recommendation was that staff ‘need to record complaints and the action that has been taken and check with the patient that it meets with their expectation’ (Clwyd and Hart, 2013:34).
This is not complicated and indeed should not have to be stated as it is so basic. The fact that it needed spelling out at all is an acute cause for concern and yet 8 years on we are still dealing with the same issues.
In the new module ‘Making sure people know how to complain and where to get support’ the following statement is made:
‘3.3 Alongside this, all staff must be aware that listening to service users and dealing with complaints is an important part of their role and one of their performance objectives. They should be:
- trained and supported in how to deal with complaints as they arise
- confident in explaining how to make a complaint and how it will be dealt with
- able to signpost people to sources of support and advice, such as your local NHS advocacy provider.’
Again, all this is not rocket science and it should not have taken nearly three decades of trying to permeate good NHS complaints-handling practice through the NHS. There is also no guarantee that the advice will become rooted in NHS practice as history does not bode well here.
In reviewing the literature over the years on NHS complaint handling and the NHS complaints system, I have found that it has been useful to look at how other services and industries guide staff on complaint handling. A message that has resonated with me and one that I feel is worth sharing is the aim to turn a complainant into an advocate for the hospital or care service. That would seem to be an excellent benchmark of success for any complaints system.
Conclusion
It is a cause of acute concern that the NHS appears to be on a never-ending journey to create a fit-for-purpose complaints system. There has been nearly three decades of trying to effect positive change, but the system is still not adequate. Recent efforts are to be welcomed as providing a positive impetus for change with clear direction. However, all this reform is taking place in an NHS that is seeing some major challenges. The NMC has pointed to a worrying trend of a developing blame culture in nursing. COVID-19 has created a working environment where many staff are stressed and vulnerable. There is a perfect storm brewing here. In order to develop a better NHS complaint system, we need to develop a just and learning culture. At the same time, we need to reflect on the overtly long journey that the NHS has taken to try and reform the NHS complaints system and to ask why steps have faltered over the years.