NHS hospital complaints: are we still going round in circles? John Tingle
I
t is hard to find positive things to say about both current and past NHS complaint systems; they all seem to have failed on every level. We seem to have gone out of our way to create complaints systems that have benefited nobody and have been so highly complex that they seemingly functioned not only to deter complaints but also to alienate those who were brave enough and dogged to negotiate them. There are, however, pockets of good complaint-handling practices in the NHS, but these seem to be the exception rather than the rule when reading reports such as the Patients Association’s (2014) and even reports from before that. We have to acknowledge that there are two options.The first is that we are never going to have a good NHS complaints system and it will prove impossible to develop a patientcentric culture in the NHS that puts patients first—and health professionals will never be able to drop their immediate defensive reactions to complaints Alternatively, there is now the political and health professional drive to build a better, patientcentric and friendly NHS complaints system. To change things for the better there must be an acknowledgement that patients are the weaker party in the care equation and that we need a complaints system that is simple and transparent, that enables complaints to be effectively resolved for all concerned without causing undue stress. A complete change in mindset is needed and, in a mammothsized organisation such as the NHS, trying to do this will be like trying to turn a fast-moving oil tanker quickly. The highly critical Patients Association report into the state of the NHS complaints system will hopefully put these issues firmly on the political agenda, and the recommendations made in the report can be seen to provide some good health complaints policy foundations that have the potential to work to greatly improve the system.
The toxic cocktail culture An interesting concept mentioned in the Patients Association (2014) report is the concept of the ‘toxic cocktail’ culture that was seen first in Clwyd and Hart (2013):
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
60
‘The PHSO [Parliamentary and Health Service Ombudsman] told the Review: “At its worst there is a toxic cocktail that prevents concerns and complaints being heard and addressed. This is a combination of reluctance on the part of patients,
families and carers to express their concerns or complaints and defensiveness on the part of hospitals and their staff to hear and address concerns. As a result opportunities to learn and improve care are lost.” PHSO provided information from research conducted in 2012. It showed 18% of patients wanted to complain, but just over half of them did not actually put in a complaint.’ (Clwyd and Hart, 2013: 28) The Patients Association (2014) refers to the ‘toxic cocktail’ culture when discussing the questions asked in the survey. In relation to question 4.5 ‘how did staff handling your complaint make you feel?’ it states that the promise made in Clwyd and Hart (2013) to change this culture does not appear to have changed nationally.
The questions asked in the survey (continued) 4.6 How stressful did you feel the process was? ■■ A
total of 66% of respondents experienced levels of stress throughout the complaints process, while only 18% said it was not stressful at all. The Patients Association comment on this finding that: ‘66% of those who participated in Patients Association surveys experienced varying levels of stress. This is unacceptable. This data is strengthened further by the correspondence and calls the organisation receives on a daily basis. Complainants tell us of the despair and high levels of anxiety, often leading to ill health; as a direct consequence of making a complaint and the lack of dignity and respect they are afforded.’ (Patients Association, 2014: 22)
This is a worrying finding; a complaints system should not exact such an emotional toll on complainants. It seems unfair and it can be seen as an affront to basic human dignity.
4.7 Throughout the process how well informed do you feel you were kept about the progress of your complaint? ■■ Less
than one third (30%) of people felt they were well informed of the progress of their complaint. ■■ Some 39% felt poorly informed, with over half of those feeling very poorly informed. The Patients Association makes the following very telling point: ‘Trusts do not appear to see the person behind the complaint.’ (Patients Association, 2014: 24)
© 2015 MA Healthcare Ltd
In the second part of his two-part column John Tingle discusses the report published by the Patients Association on the state of the NHS Complaints system
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
PATIENT SAFETY 4.8 Overall, do you think your complaint was dealt with quickly enough? ■■ Over
62% of respondents felt the process was not as quick as it should have been with half of those feeling it should have been a lot quicker ■■ It is notable that 38% of respondents felt the process had been within a satisfactory time frame.
4.9 How satisfied were you with the final response to your complaint? ■■ Over 55% of respondents reported that they were dissatisfied
with the final response they received. Of those, the majority (35%) felt very dissatisfied. The Patients Association comment section under this heading goes into more detail and states that when complainants were asked if they understood the explanation given in response to their complaint, 46 % indicated that they completely understood and 35% of respondents said they partially understood. Clearly improvements can be made in explanations to patients about their complaints.
4.10 Do you feel you have been told the truth in the response to your complaint? ■■ Only
20% of people felt that they had received a completely open and honest outcome to their complaint ■■ Over a third (36%) said they did not believe they have received an honest outcome. The Patients Association comment on this finding is hardhitting and I would certainly echo the sentiments expressed: ‘With the statutory duty of Being Open and candid allegedly embedded across the NHS, the Patients Association is appalled that the results of our survey show that over a third of those who completed our questionnaires, felt they had not received an open and honest response. ‘Sir Robert Francis is quoted as saying, “If you asked me whether poor care of the sort seen on some wards for the elderly for example in Staffordshire could occur elsewhere, I think we would say it is occurring now.” ‘Openness, honesty, transparency and learning from complaints are crucial if there is to be a culture shift in the NHS. Words may inspire, but actions are real.’ (Patients Association, 2014: 30)
4.11 Do you feel the response to your complaint explains how the Trust will take appropriate action to prevent the same thing happening again?
© 2015 MA Healthcare Ltd
■■ Half
of respondents said they do not feel improvements will be made or lessons learned as a result of their complaint ■■ Only 12% of people are confident that the trust will take appropriate action. Patients and others who have complained do appear to be suffering from a crisis of confidence as to whether lessons will be learnt from their complaints. This lack of confidence is seemingly well founded. When the totality of reports about patients complaints are read, it is often the same basic errors
British Journal of Nursing, 2015, Vol 24, No 1
that are occurring time after time. Many errors reported could have been easily avoided and concern basic matters such as failures in communication.These basic failures can and often do have profound consequences on patients’ lives. Nurses, doctors and others do not always seem to learn the lessons of the past. Many health professionals view record keeping as a chore, not something that is a fundamental prerequisite for patient safety.
The mismatch The Patients Association (2014) report draws together key themes and discusses whether the Clwyd and Hart report (2013) has made a difference. Have things improved since the publication of that seminal report on the NHS complaints system? The answer seems to be a resounding ‘no’. The clear message is that there is a fundamental mismatch; nothing seems to have really changed. On freedom for fear, for example, the Patients Association makes another very telling comment putting the issue of the adequacy of the NHS complaints system into perspective: ‘There is little evidence of the promised total culture shift in the NHS, following Sir Robert Francis’ Inquiry into Mid Staffordshire NHS Foundation Trust. Much more needs to be done to ensure patients, relatives and carers feel confident, supported and their concerns welcomed. ‘There can be no excuse for inappropriate professional behaviour or for failing to treat patients and their relatives with dignity and respect during the complaints process. (Patients Association: 34)
Patients Association recommendations Fourteen recommendations are made in the report, which aim to improve the NHS complaints system, including that the Patients Association ‘Person Friendly Charter’ for complaining should be adopted at board level across all NHS organisations and that it should be prominently displayed across the trust. Trusts must ensure a ‘no excuses’ approach for responding to complaints is adopted across the NHS (Patients Association, 2014: 43)
Conclusion The Patients Association (2014) report and recommendations are to be welcomed. Its approach is uncomplicated and after reading the report, the reader is left in no doubt whatsoever about what must happen next regarding the NHS complaints system.The present system is not fit for purpose and there must be some urgent changes made in order to make it so. Human dignity has been clearly seen to be compromised. Changing an ingrained and defensive NHS complaints culture will clearly not happen overnight and the road to reform will be a long and winding one. Sadly the NHS has been on this complaints reform road many times, and history BJN does not serve its efforts well. Patients Association (2014) Handling complaints with a compassionate human touch. http://tinyurl.com/oomtdf7 (accessed 12 December 2014) Clwyd A, Hart T (2013) A review of the NHS Hospitals Complaints System, putting patients back in the picture. Final report. http://tinyurl.com/l88ku85 (accessed 12 December 2014)
61
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
I
t is hard to find positive things to say about both current and past NHS complaint systems; they all seem to have failed on every level. We seem to have gone out of our way to create complaints systems that have benefited nobody and have been so highly complex that they seemingly functioned not only to deter complaints but also to alienate those who were brave enough and dogged to negotiate them. There are, however, pockets of good complaint-handling practices in the NHS, but these seem to be the exception rather than the rule when reading reports such as the Patients Association’s (2014) and even reports from before that. We have to acknowledge that there are two options.The first is that we are never going to have a good NHS complaints system and it will prove impossible to develop a patientcentric culture in the NHS that puts patients first—and health professionals will never be able to drop their immediate defensive reactions to complaints Alternatively, there is now the political and health professional drive to build a better, patientcentric and friendly NHS complaints system. To change things for the better there must be an acknowledgement that patients are the weaker party in the care equation and that we need a complaints system that is simple and transparent, that enables complaints to be effectively resolved for all concerned without causing undue stress. A complete change in mindset is needed and, in a mammothsized organisation such as the NHS, trying to do this will be like trying to turn a fast-moving oil tanker quickly. The highly critical Patients Association report into the state of the NHS complaints system will hopefully put these issues firmly on the political agenda, and the recommendations made in the report can be seen to provide some good health complaints policy foundations that have the potential to work to greatly improve the system.
The toxic cocktail culture An interesting concept mentioned in the Patients Association (2014) report is the concept of the ‘toxic cocktail’ culture that was seen first in Clwyd and Hart (2013):
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
60
‘The PHSO [Parliamentary and Health Service Ombudsman] told the Review: “At its worst there is a toxic cocktail that prevents concerns and complaints being heard and addressed. This is a combination of reluctance on the part of patients,
families and carers to express their concerns or complaints and defensiveness on the part of hospitals and their staff to hear and address concerns. As a result opportunities to learn and improve care are lost.” PHSO provided information from research conducted in 2012. It showed 18% of patients wanted to complain, but just over half of them did not actually put in a complaint.’ (Clwyd and Hart, 2013: 28) The Patients Association (2014) refers to the ‘toxic cocktail’ culture when discussing the questions asked in the survey. In relation to question 4.5 ‘how did staff handling your complaint make you feel?’ it states that the promise made in Clwyd and Hart (2013) to change this culture does not appear to have changed nationally.
The questions asked in the survey (continued) 4.6 How stressful did you feel the process was? ■■ A
total of 66% of respondents experienced levels of stress throughout the complaints process, while only 18% said it was not stressful at all. The Patients Association comment on this finding that: ‘66% of those who participated in Patients Association surveys experienced varying levels of stress. This is unacceptable. This data is strengthened further by the correspondence and calls the organisation receives on a daily basis. Complainants tell us of the despair and high levels of anxiety, often leading to ill health; as a direct consequence of making a complaint and the lack of dignity and respect they are afforded.’ (Patients Association, 2014: 22)
This is a worrying finding; a complaints system should not exact such an emotional toll on complainants. It seems unfair and it can be seen as an affront to basic human dignity.
4.7 Throughout the process how well informed do you feel you were kept about the progress of your complaint? ■■ Less
than one third (30%) of people felt they were well informed of the progress of their complaint. ■■ Some 39% felt poorly informed, with over half of those feeling very poorly informed. The Patients Association makes the following very telling point: ‘Trusts do not appear to see the person behind the complaint.’ (Patients Association, 2014: 24)
© 2015 MA Healthcare Ltd
In the second part of his two-part column John Tingle discusses the report published by the Patients Association on the state of the NHS Complaints system
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
PATIENT SAFETY 4.8 Overall, do you think your complaint was dealt with quickly enough? ■■ Over
62% of respondents felt the process was not as quick as it should have been with half of those feeling it should have been a lot quicker ■■ It is notable that 38% of respondents felt the process had been within a satisfactory time frame.
4.9 How satisfied were you with the final response to your complaint? ■■ Over 55% of respondents reported that they were dissatisfied
with the final response they received. Of those, the majority (35%) felt very dissatisfied. The Patients Association comment section under this heading goes into more detail and states that when complainants were asked if they understood the explanation given in response to their complaint, 46 % indicated that they completely understood and 35% of respondents said they partially understood. Clearly improvements can be made in explanations to patients about their complaints.
4.10 Do you feel you have been told the truth in the response to your complaint? ■■ Only
20% of people felt that they had received a completely open and honest outcome to their complaint ■■ Over a third (36%) said they did not believe they have received an honest outcome. The Patients Association comment on this finding is hardhitting and I would certainly echo the sentiments expressed: ‘With the statutory duty of Being Open and candid allegedly embedded across the NHS, the Patients Association is appalled that the results of our survey show that over a third of those who completed our questionnaires, felt they had not received an open and honest response. ‘Sir Robert Francis is quoted as saying, “If you asked me whether poor care of the sort seen on some wards for the elderly for example in Staffordshire could occur elsewhere, I think we would say it is occurring now.” ‘Openness, honesty, transparency and learning from complaints are crucial if there is to be a culture shift in the NHS. Words may inspire, but actions are real.’ (Patients Association, 2014: 30)
4.11 Do you feel the response to your complaint explains how the Trust will take appropriate action to prevent the same thing happening again?
© 2015 MA Healthcare Ltd
■■ Half
of respondents said they do not feel improvements will be made or lessons learned as a result of their complaint ■■ Only 12% of people are confident that the trust will take appropriate action. Patients and others who have complained do appear to be suffering from a crisis of confidence as to whether lessons will be learnt from their complaints. This lack of confidence is seemingly well founded. When the totality of reports about patients complaints are read, it is often the same basic errors
British Journal of Nursing, 2015, Vol 24, No 1
that are occurring time after time. Many errors reported could have been easily avoided and concern basic matters such as failures in communication.These basic failures can and often do have profound consequences on patients’ lives. Nurses, doctors and others do not always seem to learn the lessons of the past. Many health professionals view record keeping as a chore, not something that is a fundamental prerequisite for patient safety.
The mismatch The Patients Association (2014) report draws together key themes and discusses whether the Clwyd and Hart report (2013) has made a difference. Have things improved since the publication of that seminal report on the NHS complaints system? The answer seems to be a resounding ‘no’. The clear message is that there is a fundamental mismatch; nothing seems to have really changed. On freedom for fear, for example, the Patients Association makes another very telling comment putting the issue of the adequacy of the NHS complaints system into perspective: ‘There is little evidence of the promised total culture shift in the NHS, following Sir Robert Francis’ Inquiry into Mid Staffordshire NHS Foundation Trust. Much more needs to be done to ensure patients, relatives and carers feel confident, supported and their concerns welcomed. ‘There can be no excuse for inappropriate professional behaviour or for failing to treat patients and their relatives with dignity and respect during the complaints process. (Patients Association: 34)
Patients Association recommendations Fourteen recommendations are made in the report, which aim to improve the NHS complaints system, including that the Patients Association ‘Person Friendly Charter’ for complaining should be adopted at board level across all NHS organisations and that it should be prominently displayed across the trust. Trusts must ensure a ‘no excuses’ approach for responding to complaints is adopted across the NHS (Patients Association, 2014: 43)
Conclusion The Patients Association (2014) report and recommendations are to be welcomed. Its approach is uncomplicated and after reading the report, the reader is left in no doubt whatsoever about what must happen next regarding the NHS complaints system.The present system is not fit for purpose and there must be some urgent changes made in order to make it so. Human dignity has been clearly seen to be compromised. Changing an ingrained and defensive NHS complaints culture will clearly not happen overnight and the road to reform will be a long and winding one. Sadly the NHS has been on this complaints reform road many times, and history BJN does not serve its efforts well. Patients Association (2014) Handling complaints with a compassionate human touch. http://tinyurl.com/oomtdf7 (accessed 12 December 2014) Clwyd A, Hart T (2013) A review of the NHS Hospitals Complaints System, putting patients back in the picture. Final report. http://tinyurl.com/l88ku85 (accessed 12 December 2014)
61
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
