Can t Complain? An evaluation of information and procedures for handling complaints and gathering feedback

Transcription

1 Can t Complain? An evaluation of information and procedures for handling complaints and gathering feedback

2 Contents Foreword... 2 Executive Summary... 3 Introduction... 6 Background... 8 Methodology GP Practices NHS Trusts Commissioners: CCGs and NHS England Care Homes References Appendix: Healthwatch and ICAS C a n t c o m p l a i n? P a g e 1

3 Foreword In April 2013 Healthwatch West Sussex started its work as the independent consumer champion for health and social care locally. We are part of a network of one hundred and fifty two such organisations which cover every area of England, plus Healthwatch England, which represents consumers views nationally. Healthwatch West Sussex is a social enterprise, fully independent of the NHS, public and private providers of health and social care, the County Council and local Councils. The government have given us privileged access to local politicians and decision makers. Through Healthwatch, consumers are full partners at the Health and Wellbeing Board, the forum that has an overview of all health and social care in the County. We also have the statutory authority to Enter and View any health or care setting where public money is being spent, allowing us to review services from the consumers perspective. Healthwatch West Sussex will be a critical friend to those who commission and provide publically funded health and care services, working together to get the best deal for consumers. Healthwatch approaches this task with a degree of humility and caution. We know that the loudest voice is not always representative of the majority of people and the most important messages often come from voices that are hard to hear. We are also aware that the NHS and other care providers are striving to provide good quality, safe and efficient services. To focus our work in this first year, Healthwatch West Sussex have set these priorities: complaints adult safeguarding caring for people with dementia ensuring health and social care work in a more integrated way making sure decision-makers keep their promises. In addition, we will be active in a number of areas: listening to what people say about health and social care, including children and young people providing trained volunteers to review services from the consumers perspective we are currently planning a review of how people are using hospital Accident & Emergency services helping people with NHS complaints through our dedicated advocacy team. We want people to tell us their personal stories as consumers of health and care services, and also as carers, family members and friends. What has worked well? What needs to be improved? Details of how you can contact us are on the cover of this report. This report suggest there is much that could be done to make it easier for people to complain, to ensure the consumer voice is heard, to learn lessons and improve services. Frances Russell, Chair of Board for Healthwatch West Sussex P a g e 2 C a n t c o m p l a i n?

4 Executive Summary The ability to complain is a fundamental right for anyone who uses publically funded health or social care services. Many people receive excellent care and treatment; however, those who do have poor experiences are often reluctant to complain, or find it difficult to do so. This report investigates whether GP Practices, NHS Trusts, care homes and service commissioners are doing all they can to attract complaints from those people who have been dissatisfied with their services. The report considers the clarity and availability of information about complaints, whether procedures and policies contain sufficient detail, and the extent to which organisations are open to receiving patient feedback. The standards against which services were evaluated were taken from the key documents including the NHS Constitution, the Francis report and Healthwatch England s first Annual Report. GP practices Not all practices were successful in making information about their complaints systems easy to locate. Too many gave few details, or pages were hidden in less than obvious locations. We recommend that practices make full, detailed information about their complaints procedures available on one single web page, and ensure this is prominently displayed within premises. Information should include an explanation of what would happen if somebody made a complaint, and an explicit guarantee that complainants future treatment will not be affected. Providers should give clear details in complaints literature about the standards of service which consumers can expect, including a full list of the NHS Constitution rights and pledges. Complaints policies should give details of how these will be delivered. We would encourage all practices to ensure that their literature contains specific commitments to welcoming, valuing and learning from patient feedback and complaints. It should be possible to make a complaint via a range of different contact methods, including in person, by telephone, in writing and online. Practices should give guidance on what information to include in a complaint, and should ensure that external organisations offering support are clearly and correctly identified. Practices are strongly urged to ensure they provide their patients with regular opportunities to give meaningful feedback, for example through patient surveys. We recommend that practices ensure these include questions giving sufficient flexibility for patients to identify their thoughts and concerns on any area they wish to. Effective patient engagement often required hard work on the part of practices. It was clear that forming and maintaining effective patient groups can be well worth the time and effort. Successfully functioning groups were able to contribute strongly, providing patient-centred input into key decisions, as well as adding value to other patient surveys. C a n t c o m p l a i n? P a g e 3

5 Trusts By the nature of the treatment which Trusts give, many patients will be reliant on staff to meet both clinical and everyday needs, whether through acute care or services in the community. This means there may be more opportunities for something to go wrong or be delivered unsatisfactorily in these contexts. For this reason, Trusts should be expected to be shining examples of how to handle patient concerns effectively. Service providers need to do more to make consumers aware of procedures for handling concerns, and to promote their desire to gather feedback. In particular, Trusts should review whether sufficient provision is made to obtain detailed feedback from marginal groups. Trusts need to ensure that good quality information is available to all users who receive services in community contexts without them having to ask for it, and that users are made aware of how to raise concerns before any may have arisen. It cannot be acceptable for patients to be placed in the position whereby they have no obvious means of redress beyond directly raising their issue with the same member of staff on whom they rely for their care. PALS services, as independent sources of advice and support, have the potential to be not only a real benefit to the patients who need it, but also a significant help to Trusts in delivering effective feedback and complaints systems. Some trusts could do more to explain the range of assistance which PALS can offer, and in particular, its independent nature. Wherever possible, we would also encourage PALS teams to spend time out in wards, clinics and departments, making early contact with patients and increasing the visibility of the service. Annual Reports and Quality Accounts present a difficult balance between Trusts presenting a positive view which reassures patients and giving an objective view of current performance. Healthwatch West Sussex would rather see a more dispassionate account which balances more carefully between acknowledging positives and identifying areas for improvement. Reports tended to have the most credibility where they were most honest about shortcomings, so long as clear and specific steps were identified to address them. Trusts need to do more to think through, and to communicate clearly, what protection can be offered in regard to complainants future treatment. Often the most convincing guarantee was where all staff conveyed an attitude which welcomes critical feedback as an opportunity to learn and improve. Results from the CQC Inpatient Survey suggest that little more than one in ten patients has been asked for their views on the quality of care. Trusts should be aiming to give as many patients as possible the opportunity to provide feedback. Currently, some appear more committed to doing this than others. Trusts should also think carefully about the timing of feedback requests, as issues may be easier to address if identified early on than after discharge. Trusts should think carefully about the types and quantity of data which they collect. Short surveys may elicit more responses, but can deny patients the opportunity to share more detailed information. It is important that all users are given the opportunity to make openended free comments on any aspect of their treatment or experience that they may wish to. P a g e 4 C a n t c o m p l a i n?

6 We encourage Trusts to publish detailed findings from their own surveys. Fuller accounts of feedback from patient surveys, including more detailed action plans, would give the public more confidence that Trusts were addressing every aspect of the patient experience. Commissioners: CCGs and NHS England Each of the CCGs and NHS England has a responsibility to accept complaints about any NHS service which they commission. Information about consumers right to complain via the service commissioner is currently very limited. That which does exist seeks to downplay the role which commissioners can play. Full and detailed information should now be made available about commissioners capacity and obligation to handle complaints about services which they commission. Patient leaflets should be produced and made widely available be each CCG and by NHS England. These should provide clear guidance to help consumers decide whether to submit complaints to the provider or commissioner. Each commissioner should also require its service providers to include their details in patient information, including an explanation of the role commissioners can play in receiving and investigating complaints. Care homes The response from care homes to requests for information was very poor only two out of forty issued a reply. This is of great concern, especially given the recent backdrop of concerns about the sector nationally. It must also be in the interest of good homes to demonstrate their good practice in handling complaints openly and unambiguously. Follow up phone calls to twelve homes provided some insight into the state of complaints handling, although the small sample cannot be considered representative. Staff were not always aware of the existence of complaints policies, or did not consider that they had a role in addressing residents concerns. All staff should be expected to be familiar with the home s complaints procedure, and aware of the steps they need to take if an issue needs to be escalated. It is likely that some homes need to do more to inform residents and their families about their entitlement to raise concerns and the way they might go about doing so. More could be done to offer support and protection to residents who complain, and to inform them of third parties which they can contact. C a n t c o m p l a i n? P a g e 5

7 Introduction The aims of this report The ability to complain is a fundamental right for anyone who uses publically funded health or social care services such as GP surgeries, hospitals and care homes. Many people receive excellent care and treatment from these services. However, those who do have poor experiences are often reluctant to complain, or find it difficult to do so. This means that these organisations do not always get to hear about patients concerns, and can miss out on important information about how they can improve services. It also means that consumers can be left without effective means of obtaining redress. This report investigates whether the complaints systems of GPs, Trusts, care homes and CCGs are doing all they can to support people who have been dissatisfied in making complaints and submitting feedback. It looks at: whether clear and accurate information about complaints is easily available; whether complaints procedures are clear and detailed enough to ensure complaints are handled well; the extent to which organisations are open to hearing patients views through methods such as surveys and patient groups. Complaints and feedback As well as considering how formal complaints are handled, this report examines wider mechanisms for gathering patient feedback. Some providers treat complaints and feedback quite separately, with different procedures, literature and staff for each. Others take a more integrated approach, for example, combining Compliments, Comments, Concerns and Complaints within one department. Whatever approach is taken, both have the potential to be gather valuable intelligence from patients and consumers, and both may be avenues by which concerns can be identified and redressed. The intended audience It is likely to be the organisations which provide health and social care services which are able to take most from the report, although we hope members of the public will also be able to draw something from it. The report aims to describe the range of approaches which organisations take to handling complaints, and to discuss how these work more or less effectively for consumers. It will be for the providers themselves to compare their own approaches to the best examples given, to decide which criticisms might apply to their own current practises, and to reflect on what they can learn and improve. The report makes a number of references to the needs of those with hearing difficulties, poor mobility, low levels of English, Braille readers and learning difficulties. However, the report should not be viewed as giving comprehensive consideration to the needs of people with protected characteristics, and providers are encouraged to think beyond the specific recommendations presented. P a g e 6 C a n t c o m p l a i n?

8 The structure of the report The rationale and methodology are discussed in the early sections, after which findings are presented and discussed. It should be noted that while each chapter deals with a different type of organisation, the points made may apply to other service providers as well. In particular, the detailed comments in the GP practice section may be helpful for other organisations. C a n t c o m p l a i n? P a g e 7

9 Why look into complaints? Background Good and bad experiences of care Many people have positive experiences of health and social care. In a recent survey carried out by Healthwatch West Sussex 1, 62% of people rated their most recent visit to a health or social care provider as either good or very good. By contrast, 16% of respondents considered their last experience to have been poor, while 7% said it was very poor. These findings are echoed by a number of other national surveys. 2 3 Despite the relatively high levels of satisfaction overall, Healthwatch England 4 found that 94% of people believe that NHS and social care services could be improved. Similarly, the feedback received by Healthwatch West Sussex indicates that things don t always go right for everyone. Many of these cases demonstrate that, when things do go wrong, the impact for patients and those around them can be significant. Consumers entitlement to complain about the care and treatment they receive is important, because it is often the only way patients can get things put right. It is also a key opportunity for the people who provide these services to find out where they need to do better. Complaint systems don t always work However, the systems which providers put in place for handling complaints do not always work as well as they should. One way in which this is evident in the small number of people making complaints. Research commissioned by the Care Quality Commission 5 found that only 8% of people experiencing health or social care voiced concerns to a member of staff, and just 4% made an official complaint. While it may be tempting for organisations to view this as a positive sign, the disparity between the numbers of people expressing dissatisfaction and those making formal or informal complaints suggests there may be a real reluctance or inability on the part of consumers to complain. Healthwatch England 6 found that 54% of people who had a problem with their health or social care service in the last three years did nothing to report it. There may be a number of reasons why consumers do not complain. Firstly, complaining is not always a positive experience. The survey for the Care Quality Commission 5 reported that: 1 Healthwatch West Sussex (2013) 2 Health and Social Care Information Centre (2013) found that the proportion of people who said they were extremely or very satisfied with their care and support was 63.7 per cent in This is a measure of overall satisfaction, rather than satisfaction with a specific incident. 3 NatCen (2013, p87) reports that 61% of people in Britain are satisfied with the NHS. 4 Healthwatch England (2013a) 5 ICM (2013) 6 Healthwatch England (2013b) P a g e 8 C a n t c o m p l a i n?

10 57% of complainants did not receive a satisfactory response; 55% felt their concern was not welcomed; 34% considered that they were not treated with respect while their complaint was handled. A second reason why few consumers complain may be that they find the process difficult or confusing. Healthwatch England reports that 38% of those who complained or gave feedback said they did not find it easy to complain 6, while 61% of service users wishing to give feedback felt they had no clear way of providing this type of information. 4 Consumers appear to be confused about where and how to complain: 76% of complaints about the NHS received by the Parliamentary and Health Service Ombudsman during needed to be directed elsewhere. 7 Likewise, only 20% of complaints submitted to the General Medical Council by the public in 2012 met its threshold for investigation. 8 They noted that there is a great deal of evidence that patients find it difficult to navigate the sometimes bewildering array of organisations to which they might complain. It is therefore not surprising that the vast majority of complaints are not ones suitable for the regulator to take action on (p51). Thirdly, many consumers doubt that anything would be achieved by complaining. 25% of respondents told the CQC that they believed complaining would make no difference 5, while Healthwatch England reported that 49% of people had no confidence that formal complaints would usually be dealt with effectively. 6 Almost a quarter (23%) thought that professionals weren t really interested in what they had to say, or that they did not actively seek or listen to patients views. Fourthly, the CQC 5 identifies a number of others concerns would prevent someone from complaining: 26% of people said they would not want to be seen as a trouble maker, while 11% would not complain due to worries that they would be given worse treatment. However, the report also discusses various factors which could help to overcome these barriers. Respondents said they would be more likely to complain if: providers encouraged them to make complaints (75%); their views were actively sought, for example, through surveys (73%); providers could demonstrate how they had acted on previous complaints (70%); complaints could be made anonymously (60%); there was someone who could act as an advocate (68%). The Francis report 9 (p245) suggests some other potential barriers: a desire not to appear ungrateful for the care received, a reluctance to revisit a distressing experience, and uncertainty about whether people had good grounds for making a complaint. 7 Parliamentary and Health Service Ombudsman (2013). While the PHSO has received criticism in recent years for the small proportion of complaints which it investigated, it has pledged from April 2013 to investigate significantly more cases. However, the PHSO s role only begins once complainants have submitted their case to the organisation itself. In three-quarters of cases received by the PHSO, this has not yet been done. 8 General Medical Council (2013) 9 Francis (2013) C a n t c o m p l a i n? P a g e 9

11 Francis writes, Fears are, in part, the result of the imbalance of perceived power between the patient and the organisation. He goes on to say, the obstacles to receiving the feedback they need have to be removed by organisations providing a service to the public. If they are not, the service is deprived of vital information on what it is that requires attention A complaint that is not heard by the organisation is more damaging than a complaint that is received, acknowledged and remedied (p278). All of this suggests that the more which providers can do to ease the complaints process, assuage concerns, demonstrate attentiveness and inform consumers clearly, the more likely they are to receive the valuable information which complaints and feedback can afford. The view of the GMC 8 is that never before has it been so important to understand [the complaints being received] and to do everything possible to make sure they are handled effectively and sympathetically (p97). Standards for complaints systems A number of key documents help to define the standards against which complaints systems can be measured. The primary baseline for health services is the NHS Constitution 10, whose primary aim is to set out clearly what patients, the public and staff can expect from the NHS. 11 Social care services are covered by separate legislation 12. In addition to these, we have drawn on a number of recommendations relating to complaints handling made by the Francis Report 9 and Healthwatch England s Annual Report 2012/13. 4 The relevant aspects of these documents are outlined below. They have been used to form a number of Key Questions which have been asked of service providers. The Key Questions are listed in the Methodology section of the report. The NHS Constitution The rights which patients, public and staff are entitled to receive from NHS services are set out in the NHS Constitution. These include the right to: receive and have any complaint acknowledged within three working days; have complaints investigated properly; discuss the manner in which the complaint will be handled; know when the investigation is likely to be completed and to be kept informed of progress; know the outcome of any investigation, including an explanation of its conclusions and any actions to be taken; receive compensation where negligent treatment has caused harm; escalate the complaint to the Ombudsman if unsatisfied with the outcome, or to seek judicial review. 10 Department of Health (2013a) 11 Department of Health (2013b) 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 P a g e 1 0 C a n t c o m p l a i n?

12 In addition, the Constitution pledges to ensure that: complainants will be treated with courtesy; complainants will receive appropriate support throughout the complaints process; future treatment will not be affected; complainants will receive an appropriate explanation and apology which acknowledges any trauma experienced; the organisation will learn lessons from complaints, using them to improve services. The Handbook to the Constitution 11 notes that the rights listed above are legal entitlements protected by law, which NHS providers are obliged to obey. By contrast, the pledges made are not legally binding and cannot be guaranteed for everyone all the time. However, the NHS is committed to achieve them. The Handbook states that they express an ambition to improve, going above and beyond legal rights (p4). Therefore it seems fair to measure complaints handling systems against these aspirations as well as the legal obligations. It should be recognised, however, that the pledges are more subjective in nature than the rights. For example, support needs will vary between individuals, and providers may need to demonstrate more flexibility in these areas, perhaps discussing with the complainant what would be appropriate in that particular circumstance. Social care legislation In regards to complaints handling, care homes are governed by the Health and Social Care Act 2008 (Regulated Activities) Regulations Its requirements are summarised by the Care Quality Commission 13 as follows: People who use services, or others acting on their behalf: Are sure that their comments and complaints are listened to and acted on effectively. Know that they will not be discriminated against for making a complaint. This is because providers who comply with the regulations will: Have systems in place to deal with comments and complaints, including providing people who use services with information about that system. Support people who use services or others acting on their behalf to make comments and complaints. Consider fully, respond appropriately and resolve, where possible, any comments and complaints. 13 Outcome 17 of Care Quality Commission (2010) C a n t c o m p l a i n? P a g e 1 1

13 Francis report The Francis report 9 makes a number of recommendations in its section Complaints: process and support which are relevant to this report. Recommendation Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, although all such methods should trigger a uniform process, generally led by the provider trust. Recommendation Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually and collectively, to share their comments and criticisms with the organisation. Recommendation Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust s response should be published on its website. In addition to these formal recommendations, a number of further points are made. all patients should be entitled, should they wish it, to active support in the pursuit of their complaint going beyond what is currently offered. Many patients and their families will be suffering emotional distress or recovering from the effects of illness and be less than ideally equipped to pursue a complaint to their satisfaction (p279-80). service providers and commissioners should be required to provide a list of [support organisations] to all patients in general information and again to all those lodging complaints [ensuring] that complainants know how to access completely independent sources of support, should that be necessary (p280). it is important for trusts to document and follow through concerns raised informally as well as those which are the subject of a formal complaint (p257). it is vitally important that PALS and complaints staff readily advise people of where they can get independent advice (p275). P a g e 1 2 C a n t c o m p l a i n?

14 Healthwatch England Healthwatch England s aim, stated in its Annual Report 2012/134, is to put the voice of the public at the heart of health and social care, by adopting a new approach built around rights. A number of rights are proposed by the report, which describes itself as a working draft intended for discussion and refinement (p6). The rights are seen as encompassing the NHS Constitution, but extending more broadly beyond it. Crucially, they are also intended to apply to all types of health and social care, not just those provided by the NHS. The following rights are particularly relevant to this report: 3. I have the right to high quality, safe services that treat me with dignity, compassion and respect. 4. I have the right to information and education about what I am entitled to within the health and social care system. 6. I have the right to have my concerns and views listened to and acted upon. I have the right to be supported in taking action if I am not satisfied with the service I have received. 7. I have the right to be involved in decisions affecting services in my local community. C a n t c o m p l a i n? P a g e 1 3

15 Methodology Analysis In order to conduct a fair evaluation of complaints systems, it is important to be clear about the criteria used, and to demonstrate that it is reasonable to expect organisations to meet these standards. The criteria used are taken from the four key documents outlined in the previous section: the NHS Constitution, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, the Francis report and Healthwatch England s first Annual Report. From these, a number of Key Questions were derived; these are listed below. Each document makes a slightly different contribution to these questions: the NHS Constitution lists the obligations which NHS service providers must deliver, while the Health and Social Care Act does the same for social care providers. The Francis report identifies some strategic concerns in regards to complaints handling, and the Healthwatch England report identifies concerns raised by the public through a number of commissioned surveys. This leads to the Key Questions being used in two different ways during the analysis: in some cases, they function as an absolute measure, as all service providers are expected to meet their legal obligations. Other questions are used as a basis for drawing comparisons between the approaches of different service providers, in order to exemplify a range of practices including some of the least and the most effective. Key questions Accessibility of information Can information about complaints be found quickly and easily, in an obvious location? Is information about complaints displayed prominently within organisation premises? Do patients receiving services in other locations encounter information about complaints? Can patients and visitors access detailed information about complaints (including policies and procedures) without having to ask for it? Is information about complaints laid out clearly and explained in plain English? Is all information correct and up-to-date? Is information given about independent sources of advice and support? Are their roles explained clearly? Clear and detailed procedures Is it made clear where and how to complain? Can complaints be made in a range of different formats (e.g. in writing, in person, by telephone, online)? Is there a clear description of what will happen if somebody makes a complaint? Is it clear what patients are entitled to complain about, and what standards of service patients can expect to have received? Is guidance given on what information consumers should include when making a complaint? Are complainants encouraged to state what outcome(s) they are seeking? Are policies and procedures written clearly? P a g e 1 4 C a n t c o m p l a i n?

16 Are all the patients rights listed and explained? Do policies and procedures ensure they are delivered in practice? Inviting or discouraging complaints Does information indicate that complaints are welcomed and seen as valuable by the organisation? Does information demonstrate that complaints are taken seriously? Is a clear commitment given to resolving complaints and addressing concerns? Is there a stated commitment to learning lessons and improving services wherever possible? Are examples given of how lessons have been learned from complaints in the past? Is an explicit guarantee given that complainants future treatment will not be affected? Do policies and procedures convey an institutional ethos of openness, transparency and a culture of learning from complaints and feedback? Gathering patient views and feedback Is everyone who uses services given meaningful opportunities to provide feedback? Are patient views specifically requested (e.g. through patient surveys)? Do patient groups have meaningful input into the decisions which affect them? Is there sufficient flexibility for patients to comment on any area they may wish to, as well as specific areas on which the organisation is seeking feedback? Are both the positive and negative findings of patient feedback made public? Is there evidence that patient feedback and engagement leads to improvements being made and concerns addressed? Sample The NHS complaints procedures require members of the public to submit complaints directly to the service provider itself in the first instance 14 or the organisation who commissioned the service 15. In view of this, the approach taken in this report has been to focus on the frontline organisations providing these services: GP practices, NHS Trusts and care homes 16. In addition, the three Clinical Commissioning Groups and NHS England are considered more briefly. While West Sussex County Council are responsible for commissioning some social care, including some care homes, it was not possible to consider their role within the time constraints of this report. 14 If complainants are unhappy with the eventual outcome, they are entitled to refer the matter to the Parliamentary and Health Service Ombudsman. 15 NHS England commissions most primary care from GPs and dentists. Clinical Commissioning Groups source the majority of secondary care from hospitals and community services. 16 Time constraints meant it was not possible to consider other forms of social provision such as domiciliary and day care. For similar reasons, West Sussex County Council was not included within the discussion on commissioners. However, these organisations may find points which are relevant to their own operations in the report, and may wish to give consideration to the recommendations made. C a n t c o m p l a i n? P a g e 1 5

17 As there are a large number of GP practices and care homes within West Sussex, a selection was chosen at random 17. Fifteen GP practices and forty care homes were selected 18 ; these sample sizes were considered sufficient to capture the breadth and variety of service providers across the county while including organisations from a range of locations, sizes and configurations. All seven NHS Trusts providing services to West Sussex residents were included in the sample, along with the three Clinical Commissioning Groups and NHS England. All the organisations chosen are involved in commissioning or providing services to residents of West Sussex. Data collection Data was taken from a variety of sources. All relevant material from organisational websites was collected, including the content of web pages, online videos and downloadable documents such as leaflets, forms, brochures, Annual Reports, Quality Accounts, questionnaires and survey reports. Items which were not located online were requested from the providers; usually this involved a phone call to a relevant staff member, followed up by a formal or letter. In some cases, it was possible to obtain the most of the materials for a provider online, and it was only necessary to request specific items or to pose a few specific questions. Very occasionally, everything required was found online and it was not necessary to request any further materials. Other organisations were asked more broadly for any relevant material. Not all providers complied with requests most notably care homes although the majority of GP practices and Trusts did. It is acknowledged that the timescale of one week given to most organisations was very short. This time period was chosen very deliberately to ensure that only materials which were readily to hand and already in existence were sent. The only exceptions were to be brief details taking no more than 10 minutes to compile. All communications clearly stated these criteria, which were intended both to avoid placing an excessive time burden on organisations and to ensure that materials received gave an accurate representation of what was actually available and in use by providers. We recognise that the short timescale may have presented difficulties for some (for example, if the request arrived during staff absence or a particularly busy period). No criticism is made of individual organisations that did not send requested materials, although this did mean that opportunities may have been lost for these providers to present a fuller account of their complaints systems. Overall, it is concerning that so few care homes sent anything. Healthwatch West Sussex is very grateful to everyone who did take time to talk to us or send items. 17 A process of allocating random numbers, generated by computer, was used. This ensured that every organisation within each list stood an equal chance of being selected. 18 A list of 93 GP practices was taken from the websites of the three Clinical Commissioning Groups serving the county. 379 care homes were listed from the 2012/13 West Sussex Care Home Guide, excluding those appearing in the sections Care at Home, Day Care and Extra Care Housing. P a g e 1 6 C a n t c o m p l a i n?

18 Anonymity GP practices and care homes were promised anonymity and are not named in this report. This is for two reasons: firstly, because it was hoped that this would encourage participation and increase willingness to supply detailed information without risking public criticism; secondly, to avoid the perception that some providers were being targeted while others were not. NHS Trusts and Clinical Commissioning Groups were not treated confidentially, primarily because it was considered significantly more likely that a detailed discussion of their procedures or specific contexts would make them liable to identification even if they were not explicitly named. C a n t c o m p l a i n? P a g e 1 7

19 Accessibility of information GP Practices Finding information online Clear and easily accessible information must be a prerequisite to any effective complaints handling system. It is unlikely that many service users would be able to submit a formal complaint if they are unable to find out how to do so. More subtly, there may be some people who have grievances but who are unaware of their right to complain. Likewise, there may be many people who would have useful feedback to offer, but will not do so unless they are informed that the organisation actively encourages this information to be shared. Not all practices were successful in making information about their complaints systems easy to locate. Too many websites gave only very limited information, or none at all. In the worst examples, this tended to be hidden away in less than obvious locations, for example, on the Practice Team page (which would report that the Practice Manager would deal with complaints), or buried within a long Freedom of Information page. Other websites gave brief references on Contact Us or Contact Details pages. Many of these contained online contact form, which could be confusing as they tended to indicate that the forms were not suitable for making complaints, but gave no alternative details about how to do so. Better examples placed information on complaints within a P ractice Information or Practice Polices section. This would either be a long, single page with a wide range of information, or offer a sub menu with a specific Complaints page which might also refer to feedback, suggestions, comments, or compliments. These were more obvious places to locate information about complaints, particularly where these were clearly accessible from the website navigation menus 19. Some websites referred to complaints on several different web pages. This approach could be helpful where the information was consistent. A number gave conflicting information on different pages, such as listing different modes of contact. On other sites, visitors were required to visit several pages to gain all the necessary information a common oversight was not including the relevant contact details on the complaints page. We recommend that all practices place all their information about complaints onto a single Complaints page. This should be clearly indicated on navigation menus, and other pages should provide a link where this is relevant. 19 Horizontal or vertical menu bars which link to specific pages within the website. Complaints could either be a distinct item on the main bar, or part of a Practice Information or Practice Policies submenu. P a g e 1 8 C a n t c o m p l a i n?

20 Information within premises While websites are the most convenient external location for people seeking information about GP practices, it is while visiting the surgery itself that most people will be most mindful of how the practice conducts its business. It was not possible to verify directly whether information about complaints and feedback was displayed within surgeries, although it is known that at least one had no visible references at all. This is concerning, both because it means many users are being denied knowledge of their right to complain, but also because it sends a very poor message about whether complaints would be well received and carefully handled. Other practices provided evidence that information was displayed on premises. Some sent examples of posters or notices which informed patients of the existence of complaints procedures, welcomed comments and feedback, presented findings from previous patient surveys, and advertised patient groups. We recommend that every practice should display information about their complaints and feedback procedures in prominent and easily readable in locations such as waiting areas, on notice boards and around the reception area. The requirement to ask Irrespective of the prominence of complaints and feedback on websites and within premises, most practices failed to make good quality, detailed information easily available. This is because patients were generally required to ask at reception, or to speak to the Practice Manager. We recognise that this is likely to stem from the practices desire to resolve issues as early on and as informally as possible. While that aim may be positive in and of itself (and in line with the NHS policy of local resolution), we do not consider it acceptable for patients to have to ask for detailed information about complaints. It has already been identified that many consumers are reluctant to complain, while others feel confused about what the process would entail, or what standard of care and treatment they can reasonably expect to receive. It is important that service users are able to access this information while they are still considering whether to complain, in order to support their decision. It should not be necessary to speak to a receptionist or Practice Manager to obtain this, because however approachable and sensitive they might be, it is likely to be difficult to request the information without being asked to discuss the complaint. This issue is pertinent to many of the practices within the sample, because many had very good complaints leaflets but were failing to make these easily available to patients. Only one practice allowed visitors to download the complaints leaflet and policy from their website. We recommend that all practices make full, detailed information about their complaints procedures available on their websites. Leaflets or complaints packs should be available in locations such as waiting room tables, in leaflet racks, near notice boards and in front of reception counters. C a n t c o m p l a i n? P a g e 1 9

21 Clear and detailed procedures Clear and detailed information can only be as good as the procedures they are describing, as it is these which determine whether complaints are handled effectively, sensitively and correctly. The NHS Constitution sets out clear requirements for NHS providers to meet. We should be clear that practices which provided sufficient information all appeared to be meeting these criteria. That is to say that there were no instances in which a provider appeared to contravene, contradict or negate their legal obligations. Not all of the organisations sampled gave us detailed information, nor is it within the scope of this report to examine whether correct procedures are followed in practice. This is not to say that service users were always informed of every entitlement offered by the Constitution, nor that there weren t other aspects of complaints handling that could not be improved. A number of practices did have very clear information about complaints, but too often this was because the only thing stated was please speak to the Practice Manager. However, in general, where a detailed complaints leaflet was made available, it tended to be well written. Where practices sent their formal policies or procedures, these were also usually clearly drafted. While the intentions of the policies were obvious, some were more comprehensive than others, making specific references to the experience a complaint should have if they complained, or detailing the rights they are offered under the NHS Constitution. Where policies detailed these entitlements, we were considerably more confident that the provider had the systems in place to guarantee meeting their obligations. We recommend that complaints policies list the rights and pledges to which patients are entitled, along with details of how these will be delivered. Detailing the process A key issue for many people considering making a complaint is what would happen if they did. Effective complaints information should explain the process in detail. Many did this well, giving clear details that complaints would be acknowledged within three working days. Practices were rather more vague about how long they would take to investigate a complaint many aimed to respond within ten working days, although some allowed up to six months, mentioning that practices were free to set the own time limit. One of the rights enshrined in the NHS Constitution is the entitlement to discuss the manner in which the complaint is to be handled. A number of practices gave the impression of viewing this as optional (for example, using phrasing such as if appropriate, we will offer you a meeting to discuss further ) It is important to be clear that all complainants are entitled to such a discussion; some may decline to do so, but all should be given the opportunity. The Constitution does not define what should be discussed, but it would seem sensible for practices to take the opportunity to clarify any details of the complaint. Consideration should be taken of any concerns the complainant might have about the process (for example, they may wish their identity to be withheld if this is possible). Any individual support needs should also be identified. P a g e 2 0 C a n t c o m p l a i n?

22 There are a number of different reasons why someone might choose to complain. Complainants may be seeking a number of different outcomes, such as an apology, an explanation, having a decision overturned, receiving compensation, or simply ensuring that the experience is not repeated. A number of practices make a point of asking complainants what outcome they are seeking. We recommend that all practices to do this. This may form part of any discussion which takes place, but the question should also be posed in complaints literature and on any complaints forms. While it may not always be possible or appropriate to accede to every request, they should be borne in mind when the complaint is being investigated. As part of clarifying what the process may entail, literature should provide examples of what might happen as a result of typical complaints. Defining standards of service This relates to a further point concerning the need for practices to give an indication of the sorts of issues which people may be entitled to complaint about. One reason why people are perhaps reluctant to complain is that they may be unsure whether they have reasonable grounds for doing so. This in turn may stem from an uncertainly about what standard of service they should be able to expect from their health or social care provider. Healthwatch West Sussex sees examples on either side of this spectrum - providers may have experience of dealing with complaints which have relatively little to warrant them. But equally, they don t always get to hear about more serious issues which really should have been flagged up. An attitude of I don t want to make a fuss may be much less helpful to providers than the victim of a poor experience may realise, if it leads to them withholding a concern that may impact other people. Clearly, it is not feasible to provide an exhaustive list of issues about which complaints can be considered. However, a number of practices publish Patients Charters or make clear statements about their commitment to high standards, perhaps broken down into a small number of key areas. Where this is done well, it can give consumers a clearer idea about what the practice is aiming for, and what they are entitled to expect. Some practices set the bar high by making a commitment to continual improvement, asking to be told whenever patient s expectations are not met. This perhaps gives the most forthright indication that any suggestion, not just serious complaints, may be useful if brought to the practice s attention. We recommend that all practices give clear details in complaints literature about the standards of service which consumers can expect. Pledges The NHS Constitution makes a number of pledges which are important for shaping the experience that complainants will have. While they are not strictly mandatory, providers whose complaints systems meet them are far more likely to be able to overcome some of the barriers to complaining that many consumers feel. The focus of this report is not on assessing the extent to which the pledges are met in practice. But it is clear that few of the practices sampled communicated the protections that the pledges might offer as clearly and overtly as they could. C a n t c o m p l a i n? P a g e 2 1