How well we deal with being open and transparent with patients and their complaints is a fundamental prerequisite for attaining the development of a proper NHS patient safety culture. These are bedrock, foundational matters and if we fail on them then such a culture is beyond reach.
Unfortunately, the NHS has had long-standing problems with both complaint handling and the statutory duty of candour. These persistent issues have been the subjects of major criticism and intense debate in some recent publications, which will be discussed in this column.
Historical perspective
Disquiet with the NHS complaints system goes back a long time. A good place to look for some historical context on the NHS complaints system is the review by Clyde and Hart (2013). Many of the issues they identified are still major problems today and the authors' analysis of them is still relevant. They laid out a complaints reform timeline, discussing prior official reports and recommendations, although ‘unfortunately, many of these recommendations have not been fully implemented (Clyde and Hart, 2013: 9). The authors pulled out major themes and findings, including:
Also, they warned that all too often complainants received a negative response, and did not seem to get a fair hearing. Their view was that patients did not seem to get the support they needed when they wanted to complain, and that there did not seem to be any effective way of learning from complaints in order to bring about improvements.
Key topics in the report included why people complain and what it feels like to complain. The report was rich in detail and valuable recommendations were made.
‘There needs to be a change in the way hospital staff approach dealing with complaints. All feedback, including complaints, offer valuable information which can lead to improvements, but there has to be the right organisational ethos to enable this to happen, so that both patients and their friends or relatives and the staff involved feel supported.’
Healthwatch: a pain to complain
Moving on to the present day we have the latest Healthwatch (2025) report, on complaints and it is sad to see that many of the issues identified in Clyde and Hart (2013) are still with us, which is an acute cause for concern. A Pain To Complain is a hard hitting, clear and well researched report. It places the issue of NHS complaints in context and makes excellent recommendations, which provide a focus and agenda for change in the area. Healthwatch compares current research findings with a previous report, Suffering in Silence (Healthwatch, 2014). There is at least a decade gap between the reports and it can be seen that there are still major problems persisting with the NHS complaints system.
Key findings include:
In terms of research methodology for A Pain to Complain, this took a mixed-methods approach with polling and other methods. Part one of the polling involved a nationally representative sample of 2042 adults living in England over 17-22 October 2024. People were asked if they had experienced poor NHS care since October 2023 and about their general confidence in making complaints. There was then part two, which consisted of a boosted sample made up of 2650 adults who had experienced poor NHS care since October 2023. There were also freedom of information requests, discussion roundtables, and analysis of Healthwatch feedback on complaints.
Low confidence in the process
Less than half (48%) of the 2042 people contacted in part one polling said they would feel confident making a complaint if they experienced poor care. More than one-quarter (27%) said they would not feel confident to make a complaint. Furthermore, nearly one-quarter (24%) of the 2024 people polled had had an experience of poor NHS care in the past 12 months. This, says Healthwatch, is concerning and is double the 12% of people polled in 2014.
Healthwatch (2024) compares people's reasons for not making a complaint between its 2024 and 2014 reports in a table with percentage changes, which are generally quite marked.
‘The top deterrent for people making complaints relates to a lack of confidence in how they will be used. One-third of people (33%) did not believe that NHS organisations would use the complaint to improve services or give them an effective response, and 30% didn't think the NHS would regard their complaint as ‘serious enough’.’
A confusing process to navigate
Healthwatch found that one in five people (19%) who had experienced poor care in the past year didn't know who to contact to make a complaint. The report discusses the complaints processes, issues and what needs to change.
Delayed or poor complaint handling
Polling and roundtables revealed problems with the timeliness, empathy, and overall response to complaints:
‘In our polling, we found that 43% of people who had made a formal complaint about the poor care they had received had waited more than six months for the outcome of their complaint at the time the polling took place.’
The discussion in this section also includes the issue of dismissive or ineffective responses and that more than half of people (56%) who had made a complaint were dissatisfied with the outcome. Regarding apologies:
‘The proportion of people in 2024 who said they received an apology (19%) was much lower than in 2014, when 49% said they received an apology. This is despite the PHSO's [Parliamentary and Health Service Ombudsman] complaints standards urging NHS staff to ‘give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’, if mistakes have occurred.’
An agenda for change
There are several other findings in the Healthwatch (2024) report and it provides a good basis on which to base NHS complaints system reform. Whether matters will fundamentally change and improve must remain a matter of conjecture. History does not seem to have shown substantive improvement in NHS complaint processes being made.
Linked to the NHS complaints system is the statutory duty of candour, which has recently been the subject of a Department of Health and Social Care (DHSC) consultation, and a first official response has been published (DHSC, 2024).
The Association of Personal Injury Lawyers (APIL) produced a response to the DHSC call for evidence (APIL, 2024). This is a detailed report and should be read by government and all those concerned with patient safety and health quality. APIL highlights some key issues and challenges that must be addressed in order to build a better NHS. The statutory duty of candour is discussed along with several other issues. The following statements in the introduction set the scene well for the subsequent discussion:
‘The current fragmented approach to patient safety is not working.’
‘We are concerned that, 10 years past the implementation of the duty of candour, and despite several patient safety frameworks and programmes, the NHS is not effectively implementing the learning that comes out of patient safety incidents.’
There is a discussion of the statutory duty of candour, that compliance with it is currently sporadic with an inconsistent approach across different trusts.
‘Meaningful change in patient safety will only be possible once the NHS cover-up culture, often incentivised by those in leadership, is addressed.’
Other topics of discussion include patient access to better, clearer independent information about their rights and options. Concerns are expressed about moving more care provision to the community. There is a discussion of the use of technology in health care, challenges, and opportunities. The APIL response states that the availability of face-to-face options must not be compromised. Care should ‘be tailored to the needs of the individuals’ (APIL, 2024:5). There is a discussion of other key patient safety and health quality issues.
The APIL viewpoint is an interesting and valuable submission on the future of the NHS. It covers several key issues relating to patient safety and health quality. It is also a submission by a claimant injury lawyer association whose members have first-hand experience with patients who are alleging negligent harm or have some other concern with the NHS. Other NHS stakeholders may well hold different views but APIL's responses do provide a valuable contribution to how the NHS can perform better and an agenda for change.
Conclusion
The NHS complaints system and the statutory duty of candour are the bedrock for the development of a proper NHS patient safety culture. If these health governance and accountability systems do not operate properly then such a culture will not be achievable. We have seen through the lens of several reports and most recently Healthwatch (2025) that there are still major issues with the NHS complaints system that have been prevalent for over three decades. Healthwatch (2025) provides an excellent perspective on pressing issues with how complaints are handled in the NHS and if we are to move forward with NHS patient safety culture development, these concerns must be fully and urgently addressed.
APIL (2024) offers a useful perspective on what the organisation sees as routes to improving the NHS. This again is a well-articulated report that provides much food for thought on pressing patient safety and health quality issues. Both are to be welcomed and should be read by all those concerned with patient safety and health quality in the NHS.