Handling and resolving complaints post-Francis

The Francis report reminded us that we have a long history of trying to improve the way complaints about health services are handled. Yet we still have a long way to go to make sure patients and family members are heard and their complaints are effectively addressed.

As the Francis report noted, we’ve seen several efforts in at least the past decade to reform complaint-handling. In 2003, for example, a Department of Health paper (NHS Complaints reform: making things right) that ushered in new regulations stated:

'In a patient-centred NHS, patients should feel able to express their views – positive and negative, complaints and concerns – about the treatment and services they received, in the knowledge that they will be:

• taken seriously;
• given a speedy and effective response;
• that their views will inform learning and improvements in service delivery; and
• that there is a system for taking action to address the full range of problems which occur – from minor difficulties to major failures in treatment and care.'

In 2009, revised regulations again sought to create a more satisfactory process and ensure that lessons learned were used to improve services. The NHS Constitution gave patients the right to have complaints properly investigated.

Three important principles are reflected in the past efforts at reform. First, patients should feel comfortable and supported to file a complaint. Second, complaints should be quickly yet thoroughly investigated and answered. Third, complaints should lead to improvements. These principles are the basis of a sound complaint-handling system. 

But while some trusts have very good systems for resolving complaints, the Mid Staffordshire example shows that, despite years of trying, these principles haven’t translated into effective complaint handling in all trusts. 

So why has progress been slow?

Part of the reason is what Francis calls the 'imbalance of perceived power' between patients and health organisations. Patients or family members can be reluctant to file a complaint due to a fear of going up against a powerful trust or practice, or a fear that a complaint will negatively affect their care. This can mean that the organisation never receives the information it needs to correct a problem, while the patient never receives redress. The Francis report says: 'a complaint that is not heard by the organisation is more damaging than a complaint that is received, acknowledged and remedied.'

Another reason is that responding to complaints is fraught with emotions and fears on both sides. As patients, when we go so far as to voice our grievances to someone in a position of authority, it’s because we’ve been deeply impacted and we want action that directly responds to our concerns. If the response falls short of our expectations, it makes the hurt even greater.

For health professionals, the fear of being blamed or ostracised can create a culture that is closed to effectively responding to complaints. Colleagues may react by protecting team members because they sympathise with the challenges of consistently providing high quality care. Time pressures can lead to inadequate investigations, or cause staff and managers to sign off on empty apologies. And the frustrations of dealing with the small fraction of complaints that are without merit can colour responses to all complaints.

Francis recommended changes to again try to improve the system. One suggestion was for the NHS to review and implement an approach developed by the Patients Association.

Funded by the Health Foundation, the Patients Association project, Speaking up: Resolving NHS complaints and preventing problems from recurring, is a collaboration between the Patients Association, Mid Staffordshire and Pilgrim Projects. It works with ten acute care trusts seeking to improve complaints handling.

As part of the project, a select group of lay people, complaints managers and clinicians developed a set of 12 standards and a 'scorecard' used to measure how complaints were handled. The group act as 'peer reviewers' who examine resolved complaints at the participating trusts and provide feedback. The project’s director, Kieran Mullan, has recently been invited to join a team assisting Ann Clwyd MP and Professor Tricia Hart to conduct a review of complaints handling in the NHS in response to Francis.

Speaking Up is trying to develop good measures for helping organisations identify how far they need to go to create cultural change, as well as organisational and procedural changes, that are necessary to improve complaint resolution.

The cultural change needed is the same one that we need for true person-centred care to take hold in the NHS. Patients and health professionals should be viewed as partners who learn from each other, not as passive recipients of care on one side and expert providers of care on the other. This shift would help create an environment in which patients feel supported and confident to speak up and in which health professionals need not feel defensive, but view complaints as potential learning opportunities. 

Let’s hope it doesn’t take another decade to get there.

Sondra is a Policy Manager at the Health Foundation.