Feature

When things go wrong...

The old NHS complaints system was notorious for being confusing and unsatisfactory for all concerned. Lesley Wratten explains the thinking behind the new system, which began on 1 April

Guidelines on implementing the new NHS complaints procedure have just been published. This change appears to have emerged, at least in part, from concern about the high level of dissatisfaction among people using NHS complaints procedures.^{1 2} Health service managers and clinicians have tended to respond defensively to complaints. Responses have appeared inflexible and formulaic and often presented merely as a different version of events from the complainant’s in an attempt to place the organisation in a better light; in other words an excuse. There is little evidence to show that complaints have been taken seriously within the NHS and complaints handling has been regarded as successful once the complainant has ceased to pursue the matter further. Particularly determined and tenacious complainants who have taken their complaint further have often been critical of the medical assessors’ independence, since complaints about the clinical judgement of doctors have rarely been upheld.

Problems with the complaints system have been accentuated by the fact that today’s health service users are acting in a healthcare market and appear more ready to complain than they used to be. In 1982, according to the Department of Health, there were 16,218 complaints about NHS hospital services; in 1991/92 this had risen to 44,680. There are several explanations for this dramatic increase. It may be a reflection of a population which has become increasingly aware that it is paying for the NHS through taxation, and therefore expects a high standard for its money. It also suggests a greater willingness to challenge traditional medical practices and an increasing reluctance on the part of patients to surrender themselves to health professionals. This change of attitude is indicated not only by the rising numbers of complaints but also by the increasing numbers of people opting for holistic or complementary forms of medicine.

Moreover, the media has done a great deal to publicise matters relating to all aspects of health and healthcare, and this has raised people’s expectations of the NHS.

Recent government policy may also have affected the number of complaints by making it easier for people to complain about health services. Both the Griffiths report on NHS management in 1983 and the white paper Working for Patientsin 1989 emphasised the importance of listening to the views of health service users, and in 1985 the Hospital Complaints Procedure Act was passed, making it compulsory for hospitals to have a designated member of staff responsible for ensuring complaints were dealt with. In 1992 the Patient’s Charter was published, which identified a set of rights for patients and standards which the NHS was expected to meet, including the right to: ‘have any complaint about NHS services (whoever provides them) investigated and to get a quick reply from the trust’s chief executive or general manager’.

This increase in complaints, combined with the NHS’s poor record of complaints handling, prompted a major review of NHS complaints procedures in 1994. The recommendations of the committee were published in May 1994 in the report Being Heard.³ In response, the government has produced guidelines for implementing a single complaints procedure for all parts of the NHS, which aims to be less bureaucratic and more ‘user-friendly’. This is a move which has been universally welcomed, but does the new complaints procedure live up to expectations?

The new procedure became mandatory on 1 April 1996. It has superseded the complicated complaints procedures which was in place: the family health services procedure; the hospital complaints procedure; and the clinical complaints procedure and provides a system for dealing with complaints which is largely the same across all NHS services.

It consists of two stages. First, local resolution, when the organisation concerned will make every attempt to resolve the complaint satisfactorily through its internal complaints mechanisms. This may mean discussions with the complainant, conciliation and/or a full investigation of the circumstances. The emphasis is on flexible ways of resolving all complaints to the satisfaction of the complainant. This appears to represent an excellent opportunity for trusts and health authorities to develop innovative complaints procedures unrestricted by the formal bureaucracy that affected previous policies.

But in practice, flexibility may be limited by retention of the Patient’s Charter right for all complainants to receive a written response to their complaint signed by the chief executive. Although this is a way of ensuring that complaints are seen to be taken seriously, it may add bureaucracy to the system by acting as a barrier to informal means of resolution, such as a telephone call or a meeting, even in instances when the complainant would be satisfied by these measures. As a way of reconciling a flexible procedure with this Patient’s Charter right, some chief executives are opting for a policy of sending a letter to the complainant with a more detailed report by the manager who has dealt with the complaint. This may be a way of expediting the process in large trusts; or in small trusts which receive a particularly large number of complaints.

In addition, disciplinary procedures will be managed quite separately from complaints. This seems to represent a clear gain for GPs, dentists, opticians and pharmacists whose services are contracted by health authorities. Previously complaints about these practitioners were dealt with through the family health services complaints procedure, which was closely linked with disciplinary procedures. The aim of this procedure was to determine whether the practitioner had broken their contract with the FHSA. If, after a lengthy series of meetings and hearings, a breach was found, this sometimes led to financial penalties being imposed upon the practitioner. Apart from the obvious stress placed on the individual who was the source of complaint, the process did not necessarily meet the objectives of the complainant — nor was it designed to — and had little to do with improving the quality of services.

Although the emphasis of the new procedure is on local resolution by the trust, HA or GP practice, some complaints will inevitably remain unresolved by all internal mechanisms. These will then be referred to a non-executive director of the trust or HA who is acting as a convenor and who will screen the complaint.

The screening process will decide whether the complaint is suitable for the second stage of the new procedure, which is consideration by an independent panel. The process of convening is intended to remove the delays people faced in the old procedures when they wished their complaint to be pursued beyond local procedures. To accelerate the process, there are deadlines imposed on the convenor: four weeks are allowed for the convenor to decide whether or not to recommend an independent panel, and a further four weeks to make the necessary arrangements.

But the apparent complexity of the convenor’s role may not only make these deadlines difficult to achieve, but could add another tier of bureaucracy to what appears to be a two-stage procedure — local resolution followed by an independent panel. The workload of the convenor may also prove to be extremely onerous and many non-executive directors have legitimate anxieties about their ability to meet the demands of this role in addition to their other activities.

To preserve its independence, the panel will always have a lay majority and all types of complaint will fall within its remit. In the case of complaints which relate to clinical judgement, whether it is the clinical judgement of a medical practitioner or any other healthcare professional, independent clinical advice will be sought. A list of possible clinical assessors will be drawn up by the regional offices of the NHS Executive. This represents a broadening of the previous system of independent professional review panels, which could only deal with medical matters.

Once the panel has considered the complaint and heard the viewpoints of all parties, the results of its deliberations will be presented in a report. This will be sent in total to the complainant, the patient (if the complainant is not the patient), clinical assessors, the trust/HA chief executive and chair, or the GP and purchaser of the service. Relevant extracts will be sent to any staff members involved in the complaint. Finally, the chief executive of the trust/HA will write to the complainant to advise of any action which will be taken as a result of the complaint. This marks the end of the NHS procedure.

If a patient remains dissatisfied with the final decision of the panel, or the rejection of their complaint at any stage of the procedure, they have recourse to the health service ombudsman. The ombudsman is appointed by the Crown and is responsible to Parliament. He is not part of the NHS and is independent of the government. From 1 April 1996, his jurisdiction was extended to include matters relating to clinical judgement. In addition, he will also be able to refer the findings from his investigation to professional regulatory bodies and to investigate complaints from staff if they feel they have been unfairly treated during investigation of a complaint.

A significant factor in determining the success of the new procedure will be the way it is publicised. Although publicity about the rights of health service users is an important feature of the NHS ‘code of openness’ there is anxiety that, in the case of complaints, it may lead to a sharp increase in the number of people who wish their complaint to go to an independent panel. Since trusts and HAs will receive no additional funding for either implementing the procedure or associated staff training, this anxiety is understandable.

The target date for implementation was 1 April 1996. Although the new complaints procedure does seem to represent a clear commitment to providing a simple, fast, flexible and independent response to people who are dissatisfied with any aspect of NHS services, the additional bureaucracy and the cost to trusts and HAs when local resolution processes fail may mean the new system fares little better than the old.