The NHS has been trying for many years to get its complaints system right, but it has never succeeded. A great number of reports have been published on the system over the years, some dating back for at least a quarter of a century with the Wilson report, Being Heard (Wilson Committee, 1994). There have been regular reports into the NHS complaint handling processes ever since, yet many problems continue to persistently plague the system. Little progress has been made on developing a complaints system that is fit for purpose.
The Care Quality Commission (CQC) (2019) has just published research to support the launch of its ‘Declare Your Care’ campaign, which raises several important issues about the NHS complaints system and patients. In December the Parliamentary and Health Service Ombudsman (PHSO) published the latest quarterly report with statistics on complaints about the NHS in England (PHSO, 2018).
Before discussing these recent reports it is important to reflect on progress made to date in establishing an effective complaints system. When many past reports on NHS complaint handling are looked at a poor picture emerges.
The toxic cocktail
Clwyd and Hart (2013), in their independent review, discussed evidence given to them by the PHSO, which characterised well the central problems facing the NHS in the way it handles complaints. The ‘toxic cocktail’ phrase has been a permanent and consistent feature of the NHS complaints system for as long as I can remember:
‘The PHSO 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 a 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.”’
The PHSO also provided the review with information from research in 2012 showing 18% of patients wanted to complain, but just over half of them did not actually put in a complaint (Clwyd and Hart, 2013). The reasons for this included not knowing where or how to complain, fear they would not be listened to or taken seriously, or even fear that they would receive a worse service if they complained.
The issue of poor handling of patient complaints in 2019 is inextricably linked to the patient safety and clinical negligence debates. The same toxic cocktail could well be forcing patients to take legal proceedings to seek redress because the NHS complaints system has failed them. The defensive culture of the NHS when things go wrong succeeds in making matters even worse:
‘The NHS's culture when things go wrong appears to be predominantly defensive, rather than candid and transparent, which limits its ability to learn lessons.’
The Committee on Public Accounts also expressed concern that a lack of consistent data across the system means that the NHS does not understand why people do (or do not) make claims or the root causes of negligence.
Prompted by this, NHS Resolution commissioned a report on patient motivation to make a claim for clinical negligence (Behavioural Insights Team, 2018). The findings are unlikely to have surprised many in the NHS and elsewhere working in patient safety and health quality (Tingle, 2018). For example:
‘Reactions of NHS staff following an incident were generally considered unsatisfactory by claimants, in terms of providing adequate and appropriate explanation and apology for events. The majority of the research participants were not satisfied by the NHS complaints' handling process, in terms of communication (both verbal and written) and feeling that a meaningful outcome had been achieved.’
Putting theory into practice
There are many other reports that point to the same major failings in the NHS complaints system. These reports, spanning at least 25 years, are consistently identifying what is wrong with the system and what needs to be done to put things right. The major difficulty is that it is always easier to say things than to physically do them. As with the NHS patient safety culture development efforts, developing an effective complaints system is proving to be another elusive goal.
‘The complaints process was opaque, impersonal and lacked compassion for some. Interviewees reported lacking confidence that their complaints resulted in any meaningful outcomes.’
Declare Your Care campaign
The CQC (2019) has launched a campaign to encourage people to share their experiences of care with the regulator. This will help to support the CQC care standards improvement efforts. The CQC estimates that almost 7 million people in England who have accessed health or social care services in the last 5 years will have had concerns about their care, but never raised them. The reasons for this will come as no surprise when considering past reports. Patients’ lack of knowledge of the complaints system was one key issue raised by the survey of 2002 people:
‘The most common reasons for not raising a concern were not knowing how (20%) or who (33%) to raise it with, not wanting to be a ‘troublemaker’ (33%) and worries about not being taken seriously (28%). Over a third of people (37%) felt that nothing would change as a result.’
It is a useful exercise to contrast the latest research put out by the CQC (2019) with the findings of the Behavioural Insights Team (2018) and the Clwyd and Hart (2013) review, where common NHS complaints system failings emerge.
What is promising in the new research is the finding that when people did raise concerns or complaints, the majority (66%) found their issue was resolved quickly. This helped improve service provision and the outcome was positive for patients and the NHS. It is hoped that this positive trend will continue.
Complainants' motivations are also discussed by the CQC and again there is a clear overlap in terms of findings with the Behavioural Insights Team (2018), and others:
‘The main reasons given for raising, or wanting to raise a concern, were delays to a service or appointment, lack of information and poor patient care.’
Over a fifth of those who were surveyed raised concerns or wanted to raise concerns over communication failures between health and care services.
The CQC initiative is to be welcomed as any efforts to engage patients and carers in the patient safety, care quality improvement process is a positive step forward. Expensive litigation may also be avoided. It should be remembered that monetary compensation is not always behind a patient's decision to take legal action against the NHS. Often, they would have been satisfied with an apology, an explanation of what occurred and an assurance it will not happen again to anybody else. Not getting these answers may force patients down the litigation path. This point was made strongly by the Behavioural Insights Team (2018):
‘Themes emerging from the interviews identified that staff reactions fell below the standards expected.
‘Explanations or apologies were deemed to be rare or insufficient when they were given.
‘Several interviewees remarked that, had these initial processes been handled better, they may not have pursued their claim.’
Complaints about the NHS in England
The PHSO represents the final stage in the NHS complaints process in England. The latest quarterly report from the PHSO (2018) presents statistics on complaints about the NHS in England from July to September 2018 (quarter 2 of the financial year 2018-2019). It covers data about the complaints received, assessed and investigated and trends identified, giving insight into the scope and scale of PHSO activities. In quarter 2 it accepted 385 cases in principle for investigation involving 426 health organisations, compared with 371 cases involving 393 health organisations in quarter 1, and closed 440 compared with 459 in the preceding 3 months. The area in which the PHSO saw the most complaints about healthcare provision in quarter 2 was in hospital and community health services. The complaint issues covered included communication, failure to diagnose, delay in diagnosis, other issues relating to access to treatment or drugs, and surgical treatment.
‘Communication issues could include how clinical decisions have been explained and whether the implications were made sufficiently clear.”
These findings have been seen regularly and consistently in other reports on NHS complaint handling, sadly I would say again for nearly a quarter of a century. Unfortunately, the NHS does not seem to learn from its errors of the past and fails to change practices accordingly. The PHSO (2018) report also contains two case studies providing insights into the complaints process.
Conclusion
It is hard to be upbeat and positive about the NHS complaints system. There is a quarter of a century of reports pointing to repeated chronic problems and unlearnt lessons. The NHS complaints system can be seen to be running to stand still. There has been very little progress made to develop a system that is fit for purpose. The danger in 2019, with the NHS facing record clinical negligence costs and claims, is that failures in that system can push patients into legal action to obtain answers. Litigation claims can threaten the very sustainability of the NHS, taking scarce financial resources away from frontline care services. At the same time, patients injured by clinical negligence need to be able to access the justice system to obtain redress. By improving the NHS complaints system, we can help patients better understand what went wrong and help them achieve a just resolution of issues. Seemingly simple failures persistently dog the NHS complaints system. If we improve communication with patients that will solve many problems. The reports discussed show the mammoth task that the NHS faces in discarding the ‘toxic cocktail’ image of its complaints culture.