Human Fertility, 2014; 17(1): 45–49 © 2014 The British Fertility Society ISSN 1464-7273 print/ISSN 1742-8149 online DOI: 10.3109/14647273.2013.859745
ORIGINAL ARTICLE
A 36-month study of patient complaints at a tertiary fertility centre LYNNE ROBINSON1, JACKY COTTON1, SURUPA SARKAR1, PETER J. THOMPSON1, ARRI COOMARASAMY1,2 & MADHURIMA RAJKHOWA1 1
Birmingham Women’s NHS Foundation Trust, Birmingham,West Midlands, UK and 2School of Clinical and Experimental Medicine, University of Birmingham, Birmingham,West Midlands, UK
Abstract Patient satisfaction is an integral component of measuring health care quality. Attention to patient complaints is part of a strategy to resolve dissatisfaction and improve care. Our aim was to review patient complaints in a UK fertility centre, and their outcome. Data regarding all complaints made to the fertility services over 3 years, the outcome and actions implemented were collected retrospectively. Between 2008 and 2011, the fertility unit received 27 (6%) complaints from a total of 450 complaints for the entire Trust (NHS hospital). Complaints could be categorised as Primary Care Trust (funding body) (PCT) (n ⫽ 7) and non PCT related (n ⫽ 20). Most PCT complaints related to funding restrictions imposed by the PCT. The majority of complaints (n ⫽ 20) related to the fertility services and most complaints were multifactorial. Of the total, communication errors and administrative delays accounted for 19 out of 27 complaints, the remainder being due to staff attitude and direct clinical care issues. Of the 27, 25 (93%) were satisfied with a written response and only 2 required a further meeting; 67% of complaints were settled with an apology or explanation alone (18/27), while 30% (8/27) required a review of policy. Improved communication with patients, General Practitioners and commissioners should reduce complaints. The resolution of the majority of complaints can be achieved locally and should be used in a positive way to improve patient care.
Keywords: Complaints, fertility, communication, funding
Introduction
Anyone concerned that their complaint has not been handled satisfactorily by the NHS can now bring the matter directly to the Parliamentary and Health Service Ombudsman (PHSO). This new system replaces the old Health Care Commission (a public body which was designed to promote and improve health care) and is designed to provide a simpler, more streamlined process for the public. The PHSO investigates complaints which have not been resolved at a local level and which meet some basic criteria, such as the complaint being timely and made in writing. There has been a sharp increase in the number of complaints referred to them. In 2009, the complaints system was simplified. Instead of the old three-tiered system of referring an unresolved complaint to the Health care Commission and then if necessary the PHSO, the present two-tiered system means an unresolved complaint can go directly to the PHSO. In the same year, the PHSO dealt with 14,429 NHS health complaints (NHS Information Centre, National Statistics, 2011); a figure more than double the number received (6,780
The number of written complaints received by UK National Health Service (NHS) has risen steadily in recent years; just over 145,000 were received in 2010– 2011(NHS Information Centre, National Statistics, 2011). This rise has been attributed to a fall in standards of clinical care, higher demand for health care and an increased awareness of the complaints process. Patient complaints form an integral component of feedback within the NHS and at times lead on to litigation. A patient complaint has been defined as “an expression of dissatisfaction with a service or policy which has personally affected an individual and which requires a response in order to promote resolution between the parties concerned”. It is obligatory for all NHS organisations to operate a complaints procedure. Patient complaints in the NHS form a large part of the management workload and practitioners need to be able to deal with them promptly and effectively. Since April 2009, in England a new health complaints system has been introduced.
Correspondence: Dr Lynne Robinson, MBChB, MD, MRCOG, Birmingham Women’s NHS Foundation Trust, Mindelsohn Way, Birmingham, West Midlands B15 2TG, UK. E-mail: [email protected] (Received 20 June 2012; revised 17 February 2013; accepted 11 March 2013)
45
46 L. Robinson et al. complaints) in the previous year. This however, could in part, be due to the introduction of the simplified complaints system. Patients wishing to complain about their fertility treatment may contact the UK regulatory body, the Human Fertilisation and Embryo Authority directly regarding a clinic, although the number of these is not known due to confidentiality. Complaints can have a negative impact on the individuals concerned and lead to loss of confidence and self esteem. Worry about litigation can lead to the practice of defensive medicine, whereby responses are undertaken primarily to avoid liability rather than to benefit the patient. This lends itself to over-investigation leading to a decrease in resources which can compromise the quality of care delivered (Jain & Ogden, 1999; Korcok, 1995). However, complaints can be used as an improvement tool for care quality and should provide a stimulus for the audit and improvement of clinical practice. This can then lead to better patient care and satisfaction. There are few data in the literature on patient complaints within a fertility setting. Over a 3-year period, from 2008 to 2011 we collected data on all formal complaints to the fertility services within our Trust. The aim was to examine the types of complaints received by our fertility unit, categorise them and review how they were resolved and whether service provision was improved.
staff offered. The complaints team arrange any meetings between the complainant and the staff involved; in addition they can help to provide explanations, clarify misunderstandings and promote changes in practice. Data were collected retrospectively over a 36-month period from September 2008 to September 2011. Information was obtained from the complaints service team on all formal written complaints involving the fertility services with details of each complaint, its triage assessment and the trust’s response recorded. The outcome of the complaint was also recorded, including the method of resolution and a note was made of any complaints referred to the PHSO or any which proceeded to litigation.
Materials and methods
Types of complaints
The study was undertaken at a single teaching hospital with clinical services for the management of infertility at both secondary and tertiary level. Approximately 4,700 patients per year were seen in the Fertility Centre which carries out approximately 700 fresh in vitro fertilisation or intracytoplasmic sperm injection (IVF/ICSI) cycles annually. The hospital has a Trust complaints department which patients can contact. Patient concerns or problems which can be resolved quickly and straightforwardly are dealt with by the Patient Advice and Liaison Service (PALS) which was introduced in 2002 in hospital Trusts in England in order to make the complaints system more accessible. PALS provides a point of contact for patients and their families and can help to resolve issues and concerns and provide information and support about the complaints procedure. Formal or informal complaints or those which PALS cannot resolve are addressed by the complaint management team in the hospital. The complaints team provide an intermediate role between the complainant and those against whom the complaint is directed. All complaints received are referred to the complaints management team who triage them. Each complaint is reviewed by the Chief Executive of the Trust and written responses are requested from all staff involved. The Chief Executive compiles a summary of events, and any audit required or review in policy is also recorded in the summary. This is then sent to the complainant and a meeting with relevant
The majority of complaints (n ⫽ 20) were concerned with the fertility services but approximately one quarter (n ⫽ 7) were with primary care trust (PCT) funding-related issues (Figure 1). Of the PCT-funding related complaints (7/27), most involved PCTimposed restrictions on funding treatment such as female body–mass index (2), smoking habit (1) and the number of existing children (2). One complaint involved non compliance with guidance from the UK National Institute for Health and Care Excellence (NICE) Committee on three funded treatment cycles of IVF as the patient was only offered funding for one fresh cycle and one frozen cycle. The NICE
Results Over the 36-month period, the complaints department received 27 (6%) written complaints relating to the fertility services, out of a total of 450 complaints for the entire hospital Trust. In this time period over 14,000 out patients were seen in the secondary and tertiary infertility clinics. Although most complaints were multi factorial, they could be categorised as Primary Care Trust/funding related or Fertility services related though there was an overlap between the two categories in most complaints (Figure 1).
Figure 1. Categorisation of fertility-related complaints. Human Fertility
A 3-year study of patient complaints at a fertility centre 47 recommendations are used for clinical guidance and they recommend that up to three cycles of IVF are funded although the vast majority of PCTs in the UK will only fund one or two IVF cycles. There was also one complaint regarding a referral to the clinic when the patient had not been informed that their PCT did not fund this centre. The majority of complaints were related to the fertility services. They included (Figure 1): Clinicians’ communication errors and delays (19/27). These included delays on clinicians checking funding eligibility leading to delays in treatment (n ⫽ 7). Patients were at times referred to the centre, seen by a clinician and informed that they were being referred for NHS-funded treatment. A delay or administrative error led to them not being put on the waiting list. Other delays were due to letters being sent to wrong addresses (n ⫽ 3) and long waits for follow up appointments (n ⫽ 2). Waiting times in clinic were also the cause of some complaints (n ⫽ 2). Other communication issues involved patients not having a full explanation of their proposed treatment or a proper debrief after a procedure or surgery. Misunderstandings also occurred due to a change in the embryo grading system. Delays in being seen at clinic were often not explained to patients and the distress caused by a lengthy wait to see a clinician triggered a complaint. Failure to check that a patient would consent to a medical student being present during a consultation was cause for a complaint. Staff attitude (7/27). Patients felt that at times staff were abrupt and not empathetic. This was mainly during clinic visits with clinical staff within the Fertility services but the attitudes of other staff such as ultrasonographers and phlebotomists were also mentioned in some complaints. Direct clinical care (6/27). This involved incidences such as bleeding post egg collection and clinician mistakenly reading a semen analysis report as normal. Difficulties with embryo transfers and the lack of prescribing ferrous sulphate to an anaemic patient post operatively also were cause for complaint.
Complaint resolution Out of 27 complaints, 18 (67%) were settled with an apology alone. A further 8 (30%) were resolved with an apology and audit or review of policy; for example, following a complaint regarding waiting times in clinic it was agreed that such an audit would be carried out. Eight complainants requested funding for treatment as part of their settlement but only one was offered funding; the remaining seven were declined and the complaint resolved locally within the Trust. Out of 27 complaints, 26 were resolved at Trust level. None were referred to the PHSO in this time period compared with three throughout the rest of the trust. © 2014 The British Fertility Society
Discussion Although often distressing for staff, complaints are potentially very useful quality assurance tools and can help identify flaws in the system. Different types of complaints can lead to intervention and improvements in care. Meetings among clinical and administrative staff following a complaint can lead to significant changes in protocols and patient management or care pathways. Complaints can therefore be viewed constructively and should be looked upon as a tool for improvement of health services. Historically, the NHS has viewed its patient service as a non-judgmental function and that the clinician’s decision was paramount. Over recent years there has been a shift in emphasis such that the patient, or ‘customer’, influences the way the health service functions. Consumers today are very well informed and their lifestyles are busier and the health service needs to evolve and become increasingly flexible, informative and transparent. Our findings show that one quarter of fertility-related complaints were related to PCT-related issues. Many patients felt it was unfair that restrictions on funded treatment such as previous children, weight, age and smoking are imposed. Although NICE recommends three funded assisted reproductive treatment (ART) cycles per couple (NICE guideline 11; 2004), no PCT in the region of this study funds more than two fresh ART cycles and the majority only fund one fresh and one frozen cycle. This can seem unfair to patients. To help clarify the situation it might be helpful for trusts to provide a document for patients that clearly explains the funding criteria for different PCTs, and that these criteria have to be applied by the providers of ART services. These will clarify the situation for patients and direct them to the correct authorities if they wish to appeal. The remainder of the complaints related to the fertility services and can be grouped into (1) communication issues including administrative errors, (2) staff attitudes and (3) direct clinical care. However, there were at times multiple causes for complaints. In accordance with our findings, previous studies have reported 22–32% of complaints to be due to communication problems (Pichert et al., 1999; Taylor et al., 2002). Problems more likely to cause complaints in the fertility services were perceived delay in checking eligibility for NHS-funded treatment which can lead to distress and anxiety. Waiting times in emergency medicine have repeatedly been shown to be a prominent causative factor in patient complaints (Bursch et al., 1993; Boudreaux et al., 2000; Browne et al., 2000; Trout et al., 2000) and parallels can be drawn with waiting times for NHS-funded fertility treatment. An aid to this problem is to have written funding criteria available in all clinical areas so that eligibility can easily be checked by both clinician and patient. Better links need to be built with GPs and commissioners, ensuring that they are aware of their local funding criteria, so that patients are informed of issues such as weight
48 L. Robinson et al. loss and smoking cessation. These can be addressed prior to referral. The issue of sending letters to an incorrect address is a serious breach of patient confidentiality and needs to be addressed as a serious event with multidisciplinary input. All patients are asked to give their address when attending the outpatient clinic but measures to ensure this is done correctly would involve checking the patient’s address at every consultation and ensuring that patient labels with an old address are removed from the notes. Electronic records should help eliminate this error but until these are in place, extra vigilance is required to limit the risk of human error. Good communication between staff and patients is of paramount importance. Medical schools are now addressing the issue of communication skills training for students (Hargie et al., 1998) but a programme of regular communication training across the disciplines in those who are in clinical practice should be in place. Introduction of complaints handling as mandatory training in Trusts, along with the provision of training opportunities from professional societies will enhance the ability to prevent and manage complaints effectively. Research has shown that people move to litigation in an attempt to ensure accountability and prevent a repetition of their experience (Vincent et al., 1994). Litigation has also been shown to occur in many cases due to insensitive handling of cases and poor communication. In this study we found that at times patients were not adequately informed or misunderstood explanations and instructions. On occasions, staff were also felt to be dismissive and rude. These failings in clinical care can again lead to unnecessary angst and distress during what is often an emotional time for the patient. It is encouraging that the majority of the complaints were resolved by an apology alone. This is comparable with other studies (Taylor et al., 2002; Anderson et al., 2001) and to the findings of the PHSO report 2009–2010 which found that 25% of complaints investigated were resolved by an apology to the complainant (Parliamentary Health Service Ombudsman, 2010). Apologies are an essential and effective way of demonstrating the importance of this matter to the patient and the services. It may often be all that is required to make a patient feel valued and allow them to put the matter behind them. However, dealing with a complaint can be time consuming and often distressing, and experience as well as skill may be required to diffuse a situation. Reviews of practice illustrate how the complaints process can be improved. Patients are often reassured by the knowledge that a policy has been reviewed and action taken, so that their experience is less likely to be repeated. Although NHS complaints appear to be on the increase it is important to note that complaints are unusual; out of more than 14,000 patients over 3 years,
only 27 complaints were generated. It is also encouraging that the vast majority of complaints were resolved at the local level; consistent with other studies within the NHS and other countries which have shown that very few complaints proceed to litigation and over 95% are resolved by apology and explanation alone (Taylor et al., 2002; Siyambalapitiya et al., 2007; Anderson et al., 2001). Of those complaints referred to the PHSO, poor explanation and incomplete response were the most common reasons dissatisfaction with NHS complaint handling. Resolving complaints efficiently and quickly at a local level has been shown to be cost effective (Pietroni & de Uray-Ura, 1994). In summary, we found that complaints about fertility services differ somewhat from other areas of the NHS in that they are more frequently about funding issues and clinicians’ communication errors in the form of delays in initiation of treatment. In the light of recent enquiries within NHS trusts, attitudes to complaints must be changed and viewed as a path to improving the care provided. It is reassuring that most complaints are resolved with an empathetic response, by examining the issues raised in a constructive fashion, with assurances that practice will be improved. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References Anderson, K., Allan, D., & Finucane, P. (2001). A 30-month study of patient complaints at a major Australian hospital. Journal of Quality in Clinical Practice, 21, 109–111. Boudreaux, E.D., Ary, R.D., Mandry, C.V., & McCabe, B. (2000). Determinants of patient satisfaction in a large, municipal ED: the role of demographic variables, visit characteristics, and patient perceptions. American Journal of Emergency Medicine, 18, 394–400. Browne, G., Lam, L., Giles, H., McCaskill, M., Exley, B., & Fasher, B. (2000). The effects of a seamless model of management on the quality of care for emergency department patients. Journal of Quality in Clinical Practice, 20, 120–126. Bursch, B., Beezy, J., & Shaw, R. (1993). Emergency department satisfaction: what matters most? Annals of Emergency Medicine, 22, 586–591. Hargie, O., Dickson, D., Boohan, M., & Hughes, K. (1998). A survey of communication skills training in UK schools of medicine: present practices and prospective proposals. Medical Education, 32, 25–34. Jain, A. & Ogden, J. (1999). General practitioners’ experiences of patients’ complaints: qualitative study. British Medical Journal, 318, 1596–1599. Korcok, M. (1995). Medicolegal hell in Texas. Canadian Medical Association Journal, 153, 963–966. NHS Information Centre: Data on written complaints 2010–2011. National Statistics: NHS The Information Centre. (2011). http:// www.hscic.gov.uk. NICE Guideline. (2004) Fertility: Assessment and treatment for people with fertility problems. NICE guideline 11 2004. Parliamentary Health Service Ombudsman. (2010). Parliamentary Health Service Ombudsman Annual Report 2009-2010. Parliamentary Health Service Ombudsman. Parliamentary Health Service Ombudsman Annual Report 2010–2011. Pichert, J.W., Federspiel, C.F., Hickson, G.B., Miller, C.S., Gauld-Jaeger, J., & Gray, C.L. (1999). Identifying medical center units with disproportionate shares of patient complaints. The Joint Commission Journal on Quality Improvement, 25, 288–299. Human Fertility
A 3-year study of patient complaints at a fertility centre 49 Pietroni, P.C. & de Uray-Ura, S. (1994). Informal complaints procedure in general practice: first year’s experience. British Medical Journal, 308, 1546–1549. Siyambalapitiya, S., Caunt, J., Harrison, N., White, L., Weremczuk, D., & Fernando, D.J. (2007). A 22 month study of patient complaints at a National Health Service hospital. International Journal of Nursing Practice, 13, 107–110. Taylor, D.M., Wolfe, R., & Cameron, P.A . (2002). Complaints from emergency department patients largely result from treatment
© 2014 The British Fertility Society
and communication problems. Emergency Medicine (Fremantle), 14, 43–49. Trout, A., Magnusson, A.R., & Hedges, J.R. (2000). Patient satisfaction investigations and the emergency department: what does the literature say? Academic Emergency Medicine, 7, 695–709. Vincent, C., Young, M., & Phillips, A . (1994). Why do people sue doctors? A study of patients and relatives taking legal action. Lancet, 343, 1609–1613.
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ORIGINAL ARTICLE
A 36-month study of patient complaints at a tertiary fertility centre LYNNE ROBINSON1, JACKY COTTON1, SURUPA SARKAR1, PETER J. THOMPSON1, ARRI COOMARASAMY1,2 & MADHURIMA RAJKHOWA1 1
Birmingham Women’s NHS Foundation Trust, Birmingham,West Midlands, UK and 2School of Clinical and Experimental Medicine, University of Birmingham, Birmingham,West Midlands, UK
Abstract Patient satisfaction is an integral component of measuring health care quality. Attention to patient complaints is part of a strategy to resolve dissatisfaction and improve care. Our aim was to review patient complaints in a UK fertility centre, and their outcome. Data regarding all complaints made to the fertility services over 3 years, the outcome and actions implemented were collected retrospectively. Between 2008 and 2011, the fertility unit received 27 (6%) complaints from a total of 450 complaints for the entire Trust (NHS hospital). Complaints could be categorised as Primary Care Trust (funding body) (PCT) (n ⫽ 7) and non PCT related (n ⫽ 20). Most PCT complaints related to funding restrictions imposed by the PCT. The majority of complaints (n ⫽ 20) related to the fertility services and most complaints were multifactorial. Of the total, communication errors and administrative delays accounted for 19 out of 27 complaints, the remainder being due to staff attitude and direct clinical care issues. Of the 27, 25 (93%) were satisfied with a written response and only 2 required a further meeting; 67% of complaints were settled with an apology or explanation alone (18/27), while 30% (8/27) required a review of policy. Improved communication with patients, General Practitioners and commissioners should reduce complaints. The resolution of the majority of complaints can be achieved locally and should be used in a positive way to improve patient care.
Keywords: Complaints, fertility, communication, funding
Introduction
Anyone concerned that their complaint has not been handled satisfactorily by the NHS can now bring the matter directly to the Parliamentary and Health Service Ombudsman (PHSO). This new system replaces the old Health Care Commission (a public body which was designed to promote and improve health care) and is designed to provide a simpler, more streamlined process for the public. The PHSO investigates complaints which have not been resolved at a local level and which meet some basic criteria, such as the complaint being timely and made in writing. There has been a sharp increase in the number of complaints referred to them. In 2009, the complaints system was simplified. Instead of the old three-tiered system of referring an unresolved complaint to the Health care Commission and then if necessary the PHSO, the present two-tiered system means an unresolved complaint can go directly to the PHSO. In the same year, the PHSO dealt with 14,429 NHS health complaints (NHS Information Centre, National Statistics, 2011); a figure more than double the number received (6,780
The number of written complaints received by UK National Health Service (NHS) has risen steadily in recent years; just over 145,000 were received in 2010– 2011(NHS Information Centre, National Statistics, 2011). This rise has been attributed to a fall in standards of clinical care, higher demand for health care and an increased awareness of the complaints process. Patient complaints form an integral component of feedback within the NHS and at times lead on to litigation. A patient complaint has been defined as “an expression of dissatisfaction with a service or policy which has personally affected an individual and which requires a response in order to promote resolution between the parties concerned”. It is obligatory for all NHS organisations to operate a complaints procedure. Patient complaints in the NHS form a large part of the management workload and practitioners need to be able to deal with them promptly and effectively. Since April 2009, in England a new health complaints system has been introduced.
Correspondence: Dr Lynne Robinson, MBChB, MD, MRCOG, Birmingham Women’s NHS Foundation Trust, Mindelsohn Way, Birmingham, West Midlands B15 2TG, UK. E-mail: [email protected] (Received 20 June 2012; revised 17 February 2013; accepted 11 March 2013)
45
46 L. Robinson et al. complaints) in the previous year. This however, could in part, be due to the introduction of the simplified complaints system. Patients wishing to complain about their fertility treatment may contact the UK regulatory body, the Human Fertilisation and Embryo Authority directly regarding a clinic, although the number of these is not known due to confidentiality. Complaints can have a negative impact on the individuals concerned and lead to loss of confidence and self esteem. Worry about litigation can lead to the practice of defensive medicine, whereby responses are undertaken primarily to avoid liability rather than to benefit the patient. This lends itself to over-investigation leading to a decrease in resources which can compromise the quality of care delivered (Jain & Ogden, 1999; Korcok, 1995). However, complaints can be used as an improvement tool for care quality and should provide a stimulus for the audit and improvement of clinical practice. This can then lead to better patient care and satisfaction. There are few data in the literature on patient complaints within a fertility setting. Over a 3-year period, from 2008 to 2011 we collected data on all formal complaints to the fertility services within our Trust. The aim was to examine the types of complaints received by our fertility unit, categorise them and review how they were resolved and whether service provision was improved.
staff offered. The complaints team arrange any meetings between the complainant and the staff involved; in addition they can help to provide explanations, clarify misunderstandings and promote changes in practice. Data were collected retrospectively over a 36-month period from September 2008 to September 2011. Information was obtained from the complaints service team on all formal written complaints involving the fertility services with details of each complaint, its triage assessment and the trust’s response recorded. The outcome of the complaint was also recorded, including the method of resolution and a note was made of any complaints referred to the PHSO or any which proceeded to litigation.
Materials and methods
Types of complaints
The study was undertaken at a single teaching hospital with clinical services for the management of infertility at both secondary and tertiary level. Approximately 4,700 patients per year were seen in the Fertility Centre which carries out approximately 700 fresh in vitro fertilisation or intracytoplasmic sperm injection (IVF/ICSI) cycles annually. The hospital has a Trust complaints department which patients can contact. Patient concerns or problems which can be resolved quickly and straightforwardly are dealt with by the Patient Advice and Liaison Service (PALS) which was introduced in 2002 in hospital Trusts in England in order to make the complaints system more accessible. PALS provides a point of contact for patients and their families and can help to resolve issues and concerns and provide information and support about the complaints procedure. Formal or informal complaints or those which PALS cannot resolve are addressed by the complaint management team in the hospital. The complaints team provide an intermediate role between the complainant and those against whom the complaint is directed. All complaints received are referred to the complaints management team who triage them. Each complaint is reviewed by the Chief Executive of the Trust and written responses are requested from all staff involved. The Chief Executive compiles a summary of events, and any audit required or review in policy is also recorded in the summary. This is then sent to the complainant and a meeting with relevant
The majority of complaints (n ⫽ 20) were concerned with the fertility services but approximately one quarter (n ⫽ 7) were with primary care trust (PCT) funding-related issues (Figure 1). Of the PCT-funding related complaints (7/27), most involved PCTimposed restrictions on funding treatment such as female body–mass index (2), smoking habit (1) and the number of existing children (2). One complaint involved non compliance with guidance from the UK National Institute for Health and Care Excellence (NICE) Committee on three funded treatment cycles of IVF as the patient was only offered funding for one fresh cycle and one frozen cycle. The NICE
Results Over the 36-month period, the complaints department received 27 (6%) written complaints relating to the fertility services, out of a total of 450 complaints for the entire hospital Trust. In this time period over 14,000 out patients were seen in the secondary and tertiary infertility clinics. Although most complaints were multi factorial, they could be categorised as Primary Care Trust/funding related or Fertility services related though there was an overlap between the two categories in most complaints (Figure 1).
Figure 1. Categorisation of fertility-related complaints. Human Fertility
A 3-year study of patient complaints at a fertility centre 47 recommendations are used for clinical guidance and they recommend that up to three cycles of IVF are funded although the vast majority of PCTs in the UK will only fund one or two IVF cycles. There was also one complaint regarding a referral to the clinic when the patient had not been informed that their PCT did not fund this centre. The majority of complaints were related to the fertility services. They included (Figure 1): Clinicians’ communication errors and delays (19/27). These included delays on clinicians checking funding eligibility leading to delays in treatment (n ⫽ 7). Patients were at times referred to the centre, seen by a clinician and informed that they were being referred for NHS-funded treatment. A delay or administrative error led to them not being put on the waiting list. Other delays were due to letters being sent to wrong addresses (n ⫽ 3) and long waits for follow up appointments (n ⫽ 2). Waiting times in clinic were also the cause of some complaints (n ⫽ 2). Other communication issues involved patients not having a full explanation of their proposed treatment or a proper debrief after a procedure or surgery. Misunderstandings also occurred due to a change in the embryo grading system. Delays in being seen at clinic were often not explained to patients and the distress caused by a lengthy wait to see a clinician triggered a complaint. Failure to check that a patient would consent to a medical student being present during a consultation was cause for a complaint. Staff attitude (7/27). Patients felt that at times staff were abrupt and not empathetic. This was mainly during clinic visits with clinical staff within the Fertility services but the attitudes of other staff such as ultrasonographers and phlebotomists were also mentioned in some complaints. Direct clinical care (6/27). This involved incidences such as bleeding post egg collection and clinician mistakenly reading a semen analysis report as normal. Difficulties with embryo transfers and the lack of prescribing ferrous sulphate to an anaemic patient post operatively also were cause for complaint.
Complaint resolution Out of 27 complaints, 18 (67%) were settled with an apology alone. A further 8 (30%) were resolved with an apology and audit or review of policy; for example, following a complaint regarding waiting times in clinic it was agreed that such an audit would be carried out. Eight complainants requested funding for treatment as part of their settlement but only one was offered funding; the remaining seven were declined and the complaint resolved locally within the Trust. Out of 27 complaints, 26 were resolved at Trust level. None were referred to the PHSO in this time period compared with three throughout the rest of the trust. © 2014 The British Fertility Society
Discussion Although often distressing for staff, complaints are potentially very useful quality assurance tools and can help identify flaws in the system. Different types of complaints can lead to intervention and improvements in care. Meetings among clinical and administrative staff following a complaint can lead to significant changes in protocols and patient management or care pathways. Complaints can therefore be viewed constructively and should be looked upon as a tool for improvement of health services. Historically, the NHS has viewed its patient service as a non-judgmental function and that the clinician’s decision was paramount. Over recent years there has been a shift in emphasis such that the patient, or ‘customer’, influences the way the health service functions. Consumers today are very well informed and their lifestyles are busier and the health service needs to evolve and become increasingly flexible, informative and transparent. Our findings show that one quarter of fertility-related complaints were related to PCT-related issues. Many patients felt it was unfair that restrictions on funded treatment such as previous children, weight, age and smoking are imposed. Although NICE recommends three funded assisted reproductive treatment (ART) cycles per couple (NICE guideline 11; 2004), no PCT in the region of this study funds more than two fresh ART cycles and the majority only fund one fresh and one frozen cycle. This can seem unfair to patients. To help clarify the situation it might be helpful for trusts to provide a document for patients that clearly explains the funding criteria for different PCTs, and that these criteria have to be applied by the providers of ART services. These will clarify the situation for patients and direct them to the correct authorities if they wish to appeal. The remainder of the complaints related to the fertility services and can be grouped into (1) communication issues including administrative errors, (2) staff attitudes and (3) direct clinical care. However, there were at times multiple causes for complaints. In accordance with our findings, previous studies have reported 22–32% of complaints to be due to communication problems (Pichert et al., 1999; Taylor et al., 2002). Problems more likely to cause complaints in the fertility services were perceived delay in checking eligibility for NHS-funded treatment which can lead to distress and anxiety. Waiting times in emergency medicine have repeatedly been shown to be a prominent causative factor in patient complaints (Bursch et al., 1993; Boudreaux et al., 2000; Browne et al., 2000; Trout et al., 2000) and parallels can be drawn with waiting times for NHS-funded fertility treatment. An aid to this problem is to have written funding criteria available in all clinical areas so that eligibility can easily be checked by both clinician and patient. Better links need to be built with GPs and commissioners, ensuring that they are aware of their local funding criteria, so that patients are informed of issues such as weight
48 L. Robinson et al. loss and smoking cessation. These can be addressed prior to referral. The issue of sending letters to an incorrect address is a serious breach of patient confidentiality and needs to be addressed as a serious event with multidisciplinary input. All patients are asked to give their address when attending the outpatient clinic but measures to ensure this is done correctly would involve checking the patient’s address at every consultation and ensuring that patient labels with an old address are removed from the notes. Electronic records should help eliminate this error but until these are in place, extra vigilance is required to limit the risk of human error. Good communication between staff and patients is of paramount importance. Medical schools are now addressing the issue of communication skills training for students (Hargie et al., 1998) but a programme of regular communication training across the disciplines in those who are in clinical practice should be in place. Introduction of complaints handling as mandatory training in Trusts, along with the provision of training opportunities from professional societies will enhance the ability to prevent and manage complaints effectively. Research has shown that people move to litigation in an attempt to ensure accountability and prevent a repetition of their experience (Vincent et al., 1994). Litigation has also been shown to occur in many cases due to insensitive handling of cases and poor communication. In this study we found that at times patients were not adequately informed or misunderstood explanations and instructions. On occasions, staff were also felt to be dismissive and rude. These failings in clinical care can again lead to unnecessary angst and distress during what is often an emotional time for the patient. It is encouraging that the majority of the complaints were resolved by an apology alone. This is comparable with other studies (Taylor et al., 2002; Anderson et al., 2001) and to the findings of the PHSO report 2009–2010 which found that 25% of complaints investigated were resolved by an apology to the complainant (Parliamentary Health Service Ombudsman, 2010). Apologies are an essential and effective way of demonstrating the importance of this matter to the patient and the services. It may often be all that is required to make a patient feel valued and allow them to put the matter behind them. However, dealing with a complaint can be time consuming and often distressing, and experience as well as skill may be required to diffuse a situation. Reviews of practice illustrate how the complaints process can be improved. Patients are often reassured by the knowledge that a policy has been reviewed and action taken, so that their experience is less likely to be repeated. Although NHS complaints appear to be on the increase it is important to note that complaints are unusual; out of more than 14,000 patients over 3 years,
only 27 complaints were generated. It is also encouraging that the vast majority of complaints were resolved at the local level; consistent with other studies within the NHS and other countries which have shown that very few complaints proceed to litigation and over 95% are resolved by apology and explanation alone (Taylor et al., 2002; Siyambalapitiya et al., 2007; Anderson et al., 2001). Of those complaints referred to the PHSO, poor explanation and incomplete response were the most common reasons dissatisfaction with NHS complaint handling. Resolving complaints efficiently and quickly at a local level has been shown to be cost effective (Pietroni & de Uray-Ura, 1994). In summary, we found that complaints about fertility services differ somewhat from other areas of the NHS in that they are more frequently about funding issues and clinicians’ communication errors in the form of delays in initiation of treatment. In the light of recent enquiries within NHS trusts, attitudes to complaints must be changed and viewed as a path to improving the care provided. It is reassuring that most complaints are resolved with an empathetic response, by examining the issues raised in a constructive fashion, with assurances that practice will be improved. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
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