NHS hospital complaints: going round in circles? John Tingle In this two-part column, John Tingle discusses the new report published by the Patients Association on the state of the NHS complaints system
effectiveness of services, so should be valued and not seen in a negative light.
I
The Patients Association report
Complaints are jewels
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
1226
Another factor often forgotten is that complaints can be regarded as very important forms of patient or consumer feedback. Supermarkets, for instance, positively encourage feedback so that they can improve their services. The staff on supermarket customer-service desks always seem to deal with complaints well, and seem ‘customer-obsessed’ in a good way. Why can’t the NHS adopt the supermarket model of complaint-handling? Of course, some patients will make unreasonable complaints, but others will make reasonable ones. Complaints are a very useful way of gauging the
The Patients Association has just published a report on the state of the NHS complaints system (Patient Association, 2014), which paints a very poor picture and details well the frustrations of patients. It follows one year on from the NHS hospitals complaints review by Ann Clwyd MP and Professor Tricia Hart (Clwyd and Hart, 2013). The Patients Association report aims to establish if the recommendations made by Clwyd and Hart have come to fruition. ‘Are those who make complaints noticing a difference?’ it asks (Patients Association, 2014: 10). The report begins by noting the number of complaints in the NHS. Quoting figures from the Health and Social Information Centre, the report states that written complaints have increased by 4992 (4.6%) from 109 316 in 2012–13 to 114 308 in 2013–14. Complaints cover clinical aspects (42%); attitude and communication (22%); administration, including delays and discharge processes (19%); and all other areas (17%). The report discusses the qualitative and quantitative data collected and analysed for the report. These were taken from responses the Patients Association collated from over 1200 members of the public, who participated in their surveys between October 2013 and September 2014. The majority of survey participants had accessed acute health services. Following submission of a formal complaint, participants were asked to complete a questionnaire about their experience of the complaints system. Participants came from a diverse cross-section of British society, including a wide range of geographical locations. About 55% of those who had made a formal complaint did so regarding the care that they received individually. Roughly 45% made a complaint on behalf of somebody else, a relative or a friend. The report is structured very clearly, and is easy to read. As well as showing the survey questions and percentages of responses, it also gives comments from the Patients Association. These are quite hard-hitting and several of them are discussed below.
Questions asked in the survey 4.1: Once you had made the decision to make a complaint, how easy was it to do so? ■■ Just
over half of the respondents (55%) found the process for making complaints easy to access ■■ However, just over 20% of the respondents continue to find the process for making a complaint a difficult one. There was no analysis of the demographics of those who found it difficult.
© 2014 MA Healthcare Ltd
n my memory, the NHS complaints system has never had a good press and has never really been acknowledged as being ‘fit for purpose’. There have been numerous reports over the years, pointing out the defects of the system and the steps needed to remedy them, but nothing appears to have changed much. Each report on NHS complaints has sounded very much like the previous one, and the one before that. Over the years, each report has pointed out (among other things) poor staff attitudes, doctor, nurse and manager defensiveness towards patients, and poor communication. When it comes to NHS complaints, we seem to be stuck in groundhog day. A fundamental problem with NHS complaints systems is that complaints are seen as implacably negative and so provoke a defensive response. Health professionals and their managers seem to perceive a complaint against them as an attack by the patient on their professional integrity. What some nurses, doctors and managers fail to appreciate is the unequal power relationship between them and the patient. The patient is very much the weaker party; they are not feeling well, worrying about their condition, thinking the worst, and in a strange and unusual environment. By contrast, the nurse or doctor is on ‘home turf ’, with the body of professional knowledge that the patient so desperately needs to access. The patient is one of a number to be treated that day, that week, that year; but for the patient, it may be the most important day of their life. As professionals, nurses and doctors need to remember this power imbalance and adopt a patient-centric approach. They need to improve channels of communication with patients, explain things properly and check for understanding. In short, they need to be nice and understanding, which, sadly, does not always happen.
British Journal of Nursing, 2014, Vol 23, No 22
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
PATIENT SAFETY 4.2: If you raised concerns or the possibility of making a complaint with staff caring for you or a relative, how helpful were they? ■■ A
total of 21% of respondents found staff helpful a complaint was raised, 27% of respondents found staff to be unhelpful. The comment on this section from the Patients Association is very forceful and leaves no doubt that very serious problems still exist: ■■ When
‘One year on from the Clwyd-Hart report, patients continue to face huge barriers when complaining. They tell us of the hostility and inappropriate professional behaviour they are subjected to. This equates to a lack of openness, honesty and adherence to a statutory duty of being open by many Trusts. There is little evidence of the promised total culture shift in the NHS following Sir Robert Francis’ inquiry into Mid Staffordshire NHS Foundation Trust. With only 21% of respondents finding staff helpful, we conclude that much more needs to be done to ensure patients, relatives and carers feel confident, supported and their concerns welcomed. As Sir Robert Francis said recently, “Hospital nurses and doctors should be as helpful as the staff at Waitrose.”’ (Patients Association, 2014: 16–17)
4.3: Before you made your complaint, were you worried that the quality of your care (or friend or relative) would be affected if you complained? ■■ A
total of 31% of respondents felt comfortable that the quality of care would not be affected by complaining ■■ Half of respondents (50%) had concerns that the quality of care received would be affected if they made a complaint ■■ Of those 50%, 21% felt certain that there would be repercussions if they complained. This is a very worrying finding, as it shows that some patients strongly believe that complaining will only make matters worse. Even if this belief is false, what matters is that it is held by a significant number of patients and needs to be urgently addressed. The Patients Association comment on this section is very hard-hitting again:
© 2014 MA Healthcare Ltd
‘It is appalling that 50% of those who responded to our surveys told us they were scared to make a complaint for fear that their care would be affected. This should not be allowed to happen. We should have learned from all the high-profile public inquiries and reports over the last few years. Hospital boards and staff must accept the principles of being open and acknowledge the learning that must be taken from concerns and complaints raised.’ (Patients Association, 2014: 18)
4.4: Overall, how well do you feel your complaint was handled? ■■ A
total of 29% of the respondents said their complaint was handled well or very well
British Journal of Nursing, 2014, Vol 23, No 22
■■ Nearly
half of the respondents (46%) said the complaint was poorly handled, with 26% stating that it was very poorly handled. Again, these are worryingly poor satisfaction figures and show fundamental underlying problems in the NHS complaints system. The Patients Association comments: ‘With nearly half the respondents telling us they felt their complaints were poorly handled, we have to conclude that the complaints processes in many Trusts are inadequate and failing those who complain. There still appears to be little public confidence in the NHS complaints process. We have to question why patients and their relatives find it is so difficult to communicate with a health professional directly.’ (Patients Association, 2014: 19)
4.5: How did staff handling your complaint make you feel? ■■ Around
a third (33%) of respondents were made to feel comfortable throughout the complaints process, with only 8% of those feeling very comfortable ■■ A total of 30% of respondents said they were made to feel uncomfortable ■■ A total of 32% of respondents were unsure how they felt throughout the process. The Patients Association commented: ‘It is a sad indictment of our NHS that patients, relatives and carers continue to find making a complaint an uncomfortable and distressing process. The Patients Association receives calls on a daily basis from people who feel despair and desperation with the complaints systems. A third of patients are left feeling uncomfortable and alone as they navigate a complex and lengthy process. This is unacceptable.’ (Patients Association, 2014: 20)
Conclusion This column is in two parts. This first part has explored NHS complaints and introduced the Patients Association keynote report on NHS complaints procedures. It can be seen immediately that, despite the reports by Francis (2013) and Clwyd and Hart (2013), things hardly seem to have changed with regard to NHS culture around complaints. Patients are still having a very hard time complaining, and many feel generally let down by a system that was designed to be a fair, effective and transparent way of dealing with complaints. It is clear that the NHS would benefit from a more ‘retaillike’ approach to dealing with complaints. At present, it does not appear to be patient-friendly; instead, it seems an odd and complex system that has grown up over many years into BJN a fairly unfathomable process. 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 1 December 2014) Francis R (2013) Final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://tinyurl.com/anb9zme (accessed 1 December 2014) Patients Association (2014) Handling Complaints with a Compassionate Human Touch. http://tinyurl.com/oomtdf7 (accessed 1 December 2014)
1227
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
effectiveness of services, so should be valued and not seen in a negative light.
I
The Patients Association report
Complaints are jewels
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
1226
Another factor often forgotten is that complaints can be regarded as very important forms of patient or consumer feedback. Supermarkets, for instance, positively encourage feedback so that they can improve their services. The staff on supermarket customer-service desks always seem to deal with complaints well, and seem ‘customer-obsessed’ in a good way. Why can’t the NHS adopt the supermarket model of complaint-handling? Of course, some patients will make unreasonable complaints, but others will make reasonable ones. Complaints are a very useful way of gauging the
The Patients Association has just published a report on the state of the NHS complaints system (Patient Association, 2014), which paints a very poor picture and details well the frustrations of patients. It follows one year on from the NHS hospitals complaints review by Ann Clwyd MP and Professor Tricia Hart (Clwyd and Hart, 2013). The Patients Association report aims to establish if the recommendations made by Clwyd and Hart have come to fruition. ‘Are those who make complaints noticing a difference?’ it asks (Patients Association, 2014: 10). The report begins by noting the number of complaints in the NHS. Quoting figures from the Health and Social Information Centre, the report states that written complaints have increased by 4992 (4.6%) from 109 316 in 2012–13 to 114 308 in 2013–14. Complaints cover clinical aspects (42%); attitude and communication (22%); administration, including delays and discharge processes (19%); and all other areas (17%). The report discusses the qualitative and quantitative data collected and analysed for the report. These were taken from responses the Patients Association collated from over 1200 members of the public, who participated in their surveys between October 2013 and September 2014. The majority of survey participants had accessed acute health services. Following submission of a formal complaint, participants were asked to complete a questionnaire about their experience of the complaints system. Participants came from a diverse cross-section of British society, including a wide range of geographical locations. About 55% of those who had made a formal complaint did so regarding the care that they received individually. Roughly 45% made a complaint on behalf of somebody else, a relative or a friend. The report is structured very clearly, and is easy to read. As well as showing the survey questions and percentages of responses, it also gives comments from the Patients Association. These are quite hard-hitting and several of them are discussed below.
Questions asked in the survey 4.1: Once you had made the decision to make a complaint, how easy was it to do so? ■■ Just
over half of the respondents (55%) found the process for making complaints easy to access ■■ However, just over 20% of the respondents continue to find the process for making a complaint a difficult one. There was no analysis of the demographics of those who found it difficult.
© 2014 MA Healthcare Ltd
n my memory, the NHS complaints system has never had a good press and has never really been acknowledged as being ‘fit for purpose’. There have been numerous reports over the years, pointing out the defects of the system and the steps needed to remedy them, but nothing appears to have changed much. Each report on NHS complaints has sounded very much like the previous one, and the one before that. Over the years, each report has pointed out (among other things) poor staff attitudes, doctor, nurse and manager defensiveness towards patients, and poor communication. When it comes to NHS complaints, we seem to be stuck in groundhog day. A fundamental problem with NHS complaints systems is that complaints are seen as implacably negative and so provoke a defensive response. Health professionals and their managers seem to perceive a complaint against them as an attack by the patient on their professional integrity. What some nurses, doctors and managers fail to appreciate is the unequal power relationship between them and the patient. The patient is very much the weaker party; they are not feeling well, worrying about their condition, thinking the worst, and in a strange and unusual environment. By contrast, the nurse or doctor is on ‘home turf ’, with the body of professional knowledge that the patient so desperately needs to access. The patient is one of a number to be treated that day, that week, that year; but for the patient, it may be the most important day of their life. As professionals, nurses and doctors need to remember this power imbalance and adopt a patient-centric approach. They need to improve channels of communication with patients, explain things properly and check for understanding. In short, they need to be nice and understanding, which, sadly, does not always happen.
British Journal of Nursing, 2014, Vol 23, No 22
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
PATIENT SAFETY 4.2: If you raised concerns or the possibility of making a complaint with staff caring for you or a relative, how helpful were they? ■■ A
total of 21% of respondents found staff helpful a complaint was raised, 27% of respondents found staff to be unhelpful. The comment on this section from the Patients Association is very forceful and leaves no doubt that very serious problems still exist: ■■ When
‘One year on from the Clwyd-Hart report, patients continue to face huge barriers when complaining. They tell us of the hostility and inappropriate professional behaviour they are subjected to. This equates to a lack of openness, honesty and adherence to a statutory duty of being open by many Trusts. There is little evidence of the promised total culture shift in the NHS following Sir Robert Francis’ inquiry into Mid Staffordshire NHS Foundation Trust. With only 21% of respondents finding staff helpful, we conclude that much more needs to be done to ensure patients, relatives and carers feel confident, supported and their concerns welcomed. As Sir Robert Francis said recently, “Hospital nurses and doctors should be as helpful as the staff at Waitrose.”’ (Patients Association, 2014: 16–17)
4.3: Before you made your complaint, were you worried that the quality of your care (or friend or relative) would be affected if you complained? ■■ A
total of 31% of respondents felt comfortable that the quality of care would not be affected by complaining ■■ Half of respondents (50%) had concerns that the quality of care received would be affected if they made a complaint ■■ Of those 50%, 21% felt certain that there would be repercussions if they complained. This is a very worrying finding, as it shows that some patients strongly believe that complaining will only make matters worse. Even if this belief is false, what matters is that it is held by a significant number of patients and needs to be urgently addressed. The Patients Association comment on this section is very hard-hitting again:
© 2014 MA Healthcare Ltd
‘It is appalling that 50% of those who responded to our surveys told us they were scared to make a complaint for fear that their care would be affected. This should not be allowed to happen. We should have learned from all the high-profile public inquiries and reports over the last few years. Hospital boards and staff must accept the principles of being open and acknowledge the learning that must be taken from concerns and complaints raised.’ (Patients Association, 2014: 18)
4.4: Overall, how well do you feel your complaint was handled? ■■ A
total of 29% of the respondents said their complaint was handled well or very well
British Journal of Nursing, 2014, Vol 23, No 22
■■ Nearly
half of the respondents (46%) said the complaint was poorly handled, with 26% stating that it was very poorly handled. Again, these are worryingly poor satisfaction figures and show fundamental underlying problems in the NHS complaints system. The Patients Association comments: ‘With nearly half the respondents telling us they felt their complaints were poorly handled, we have to conclude that the complaints processes in many Trusts are inadequate and failing those who complain. There still appears to be little public confidence in the NHS complaints process. We have to question why patients and their relatives find it is so difficult to communicate with a health professional directly.’ (Patients Association, 2014: 19)
4.5: How did staff handling your complaint make you feel? ■■ Around
a third (33%) of respondents were made to feel comfortable throughout the complaints process, with only 8% of those feeling very comfortable ■■ A total of 30% of respondents said they were made to feel uncomfortable ■■ A total of 32% of respondents were unsure how they felt throughout the process. The Patients Association commented: ‘It is a sad indictment of our NHS that patients, relatives and carers continue to find making a complaint an uncomfortable and distressing process. The Patients Association receives calls on a daily basis from people who feel despair and desperation with the complaints systems. A third of patients are left feeling uncomfortable and alone as they navigate a complex and lengthy process. This is unacceptable.’ (Patients Association, 2014: 20)
Conclusion This column is in two parts. This first part has explored NHS complaints and introduced the Patients Association keynote report on NHS complaints procedures. It can be seen immediately that, despite the reports by Francis (2013) and Clwyd and Hart (2013), things hardly seem to have changed with regard to NHS culture around complaints. Patients are still having a very hard time complaining, and many feel generally let down by a system that was designed to be a fair, effective and transparent way of dealing with complaints. It is clear that the NHS would benefit from a more ‘retaillike’ approach to dealing with complaints. At present, it does not appear to be patient-friendly; instead, it seems an odd and complex system that has grown up over many years into BJN a fairly unfathomable process. 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 1 December 2014) Francis R (2013) Final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. http://tinyurl.com/anb9zme (accessed 1 December 2014) Patients Association (2014) Handling Complaints with a Compassionate Human Touch. http://tinyurl.com/oomtdf7 (accessed 1 December 2014)
1227
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
