briefing Hard Truths what you need to know 3. Effective complaints handling January 2014 Introduction

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1 briefing January 2014 Hard Truths what yu need t knw 3. Effective cmplaints handling Key pints N majr changes t prcess but general themes f increased penness and scrutiny Cmplaints and cmplaints handling subject t new levels f scrutiny, including hspital inspectins and mandatry reprting t the CQC A new system fr publishing cmplaints, allwing cmparisn f hspitals Intrductin This subject has been ne that has trubled the NHS fr many years and a system that is effective and efficient seems t be almst impssible t achieve. Rbert Francis QC heard evidence n the subject frm patients, relatives and thse engaged in running the prcess itself, during his inquiry. It was a srry tale t hear and t read abut in his subsequent reprt. In summary there were tw imprtant failings. Firstly, that the system let dwn patients and did nt address the cncerns that they had and secndly, that the NHS and its regulatrs did nt use the infrmatin cntained in the cmplaints t either imprve services r as a tl t highlight pr practice within the system generally. The NHS cmplaints service that Rbert Francis QC heard evidence abut related t bth the three and the tw tiered system. The three tiered system was where the Trust was respnsible fr the initial review f the cmplaint with a secnd ptin f referral t the Healthcare Cmmissin. If the persn remained dissatisfied then there was a final ptin f referral t the Health Service Ombudsman. The Healthcare Cmmissin struggled t deal with their part in this, as it was a system that did nt fit cmfrtably with the respnsibilities and aims f the regulatr at the time. It was placed there as there was nwhere else t put it. The current system which effectively cuts ut the regulatr frm the prcess was als cnsidered by Rbert Francis. It was evident that neither system prvided prper satisfactin fr patients and it was als evident that the infrmatin that cmplaints culd give the NHS was nt effectively harnessed either. S, nw that a public inquiry has cnsidered the issues and the gvernment has als had time t cnsider the recmmendatins are we near a slutin t the highlighted prblems? A mre detailed review f the Clywd/Hart recmmendatins tgether with the gvernment s respnse t Francis is attached as an appendix t this briefing nte. 1

2 Summary f future actins t be taken The prpsed actin that the Gvernment will take as a result f Francis and Clwyd and Hart is as fllws: There will be a review f the patient and advice liaisn services in 2014 (including cmmissining f NHS cmplaints advcacy services). Cmplaints will be a key part f the new Chief Inspectr f hspitals inspectins wh will lk at hw well a trust deals with cmplaints and which will invlve lking at a sample f real life cmplaints and what actin was taken as well as talking t patients. The Chief Inspectr will als publish a thematic reprt n themes and trends in cmplaints data emerging during the hspital inspectins. The Parliamentary and Health Service Ombudsman and Healthwatch England will wrk with the Department f Health and develp a patient led visin and expectatins fr cmplaints handling in the NHS. The Parliamentary and Health Service Ombudsman will wrk with the Care Quality Cmmissin n what insight can be prvided n cmplaints that she has investigated in rder t infrm hspital inspectins. The Gvernment will explre with NHS England and ther partners the intrductin f a regular and standard way f surveying peple wh have made a cmplaint t find ut whether they were satisfied with the way it was handled which will enable a cmparisn t be made acrss hspitals. The Department f Health will wrk with the Health and Scial Care infrmatin centre t put cmplaints data int the existing NHS electrnic data cllectin system which will enable their t be cmparisn between hspitals. The Chief Inspectr and Care Quality Cmmissin will require regular reprting f cmplaints frm all prviders t infrm its surveillance and risk prfiling regime. There will be a re-fcus fr the Parliamentary and Health Service Ombudsman and the ambitin is that there will be a significant increase t the number f cases that the Ombudsman is able t take n. Department f Health will wrk with Healthwatch England and the Lcal Gvernment Assciatin t develp a set f gd practice standards fr NHS Cmplaints Advcacy Services. Cnclusin In cnclusin, in the future the public shuld be clearer abut hw and t whm they can cmplain and they shuld have mre supprt available if they wish t have it. The NHS will be required t publish infrmatin abut cmplaints mre widely, CQC will inspect hw trusts have respnded t cmplaints made and if rganisatins have learned lessns as a result. Infrmatin abut cmplaints shuld be used mre widely t spt ptential prblems develping in the future, with the aim that the infrmatin will be used t highlight and avid the tragedies that happened at Mid Staffs. The structure f the cmplaints prcess will nt change and nr shuld it. There is nthing particularly new in the recmmendatins made r the gvernment respnse t them in relatin t handling cmplaints. This aspect f the inquiry, as with s many thers, cannt be seen in islatin. If there is a real will t learn frm mistakes and be pen with patients then the current cmplaints prcess will have a chance f wrking in the future. 2

3 Appendix A review f the NHS Hspitals Cmplaint System: Putting Patients Back in the Picture - Clywd and Hart Yu will all be aware that the gvernment s initial respnse t Francis, befre publishing Hard Truths, was t ask the Right Hnurable Ann Clwyd MP and Prfessr Tricia Hart, Chief Executive f Suth Tees Hspital NHS Fundatin Trust t carry ut an independent review int best practice in cmplaints handling t ensure that the mst effective system culd be cmmissined in the future. The review, nt surprisingly, cnfirmed what Rbert Francis had already established during the Inquiry. In summary it fund : Vulnerable peple find the cmplaint system cmplicated and hard t navigate; A lw level f public awareness f the NHS cmplaints advcacy service; A reluctance t cmplain and defensive staff wh are reluctant t listen; Organisatins wh d nt always deliver n legislative respnsibility; A need fr staff t be trained n quality in respnding t cmplaints. One f the mst imprtant aspects f the recmmendatins made by the review was that the Chief Executive f the rganisatin shuld take persnal respnsibility fr the cmplaints prcedure, which shuld include signing ff letters respnding t cmplaints when they related t serius care failings. It als reiterated that there shuld be bard led scrutiny f cmplaints with mnthly reprts n cmplaints, including actin taken. It is expected that directrs with respnsibility fr patient safety wuld be required t give a detailed update n cmplaints at each Bard meeting and that Bards wuld see regular data abut cmplaints. Updates wuld include narrative and nt just numbers s that themes and recurring prblems can be identified. In sme trusts, patients are already invited t Bard meetings s that they are able t share their stry s that the Bard can understand the issues directly frm the patients themselves. 3

4 The Francis Recmmendatins and the Gvernment s respnse Recmmendatin Lwering Barriers 109/111: Ensuring there is a clear and easy methd t register a cmplaint and that an rganisatin prmtes t the public their desire t receive and learn frm cmments and cmplaints and that patients shuld be encuraged t share cmments and criticisms. 110: Litigatin shuld nt be a barrier t the prcessing r investigatin f a cmplaint at any level. 112: Patient feedback which is nt in the frm f cmplaint but suggests cause fr cncern shuld be the subject f investigatin and respnse. Analysis The gvernment says that there shuld be a sign in every ward in a clinical setting that sets ut clearly fr patients hw t cmplain abut the hspital, hw t seek supprt frm their lcal Healthwatch and hw patients can refer their cmplaint t the Health Service Ombudsman. The gvernment will als supprt Healthwatch England in crdinating a cnsumer faced cmplaints campaign (this wuld seem t be the patient led visin and expectatins fr cmplaints handling referred t at recmmendatin 113). The gvernment als supprts the recmmendatins made in the Hart and Clwyd review in putting pencil and paper by a persn s bedside and using vlunteers t supprt patients in expressing cncerns especially if they are vulnerable r alne. The Care Quality Cmmissin will nw include cmplaints handling in its assessment f Trust perfrmance including hw a Trust has learned frm cmplaints in the past. Regulatrs have in the past assessed a Trust s cmplaint handling recrd but a fcus n learning frm the cmplaints made, is a slightly new fcus. Befre April 2009, where a cmplaint was received when it had als been indicated in writing that the persn invlved was intending t take legal prceedings, the cmplaint culd be excluded frm the NHS Cmplaints arrangements. In 2009 the Department f Health remved this regulatin because it cnsidered there shuld be n direct link between respnding t a cmplaint and the cnsideratin f litigatin. NHSLA guidance has supprted this fr smetime s it seems unlikely that this recmmendatin will make much difference t the current arrangements. In practice this may be difficult t mnitr especially if the feedback is given rally, hwever the principle must be crrect. The pint is, that there shuld nt be an artificial distinctin between a cncern and a cmplaint if it raises a ptential patient safety issue. Cmplaints handling 113: The recmmendatins and standard suggested by the Patients Assciatins peer review int cmplaints f the Mid-Staffrdshire NHS Fundatin Trust shuld be reviewed and implemented in the NHS. Currently standards f cmplaints handling are judged n the basis f the 2009 Regulatins and the Health Service Ombudsman s Principles f Gd Cmplaints Handling. Althugh the recmmendatin is accepted, rather than accepting the Patient s Assciatin peer review already available, the gvernment intends t publish a mre frmal statement f standards expected in cmplaints handling. The Health Service Ombudsman and Healthwatch England will develp a patient led visin and expectatins fr cmplaints handling in the NHS in the future. 4

5 Recmmendatin 114: cmments r cmplaints which describe events amunting t a serius r untward incident shuld trigger an investigatin. in principle Independent Investigatins 115: That an arms length independent investigatin f the cmplaint shuld be initiated where the fllwing applies: A cmplaint amunts t an allegatin f a serius untward incident. The subject matter invlves clinically related issues nt capable f reslutin withut an expert clinical pinin A cmplaint raises substantive issues f prfessinal miscnduct r perfrmance f senir managers It invlves issues abut the nature and extent f the services cmmissined. Analysis The gvernment accepts that there shuld be independent lcal investigatin althugh it is nt clear what this will mean in practice. Mst decisins abut an investigatin relating t a incident, will be based upn the rganisatins wn views n hw the facts fit within the definitin f serius untward incident and if there is a requirement fr an investigatin. The gvernment reminds us that the Serius Incident Framewrk ntes that a grading f an incident shuld err n the side f cautin and categrise and treat an incident as serius if there is any pssibility that it is. We are tld that CQC will cnsider hw it can give greater prminence t cmplaints and safety alerts in its revised inspectin mdel. Althugh the principle is accepted by the gvernment it is nt clear hw the principle will be mnitred by CQC t ensure investigatins are carried ut in the cases that they shuld be. The recmmendatin is accepted in part as the gvernment wishes t set the principle f independent investigatin in the cntext f prprtinality. The gvernment is cncerned that there culd be an veruse f independent investigatins in cmplaints which d nt warrant it. It is stated that the need fr independent investigatin must be determined in cnjunctin with the relevant NHS cmmissiner and investigatins fr less serius incidents can be undertaken by the rganisatins themselves as lng as the staff undertaking the investigatin are sufficiently remved frm the incident t be able t prvide an bjective view. Again, a matter f interpretatin! In rder t prtect resurces the gvernment cnsiders that in cases where it is nt clear that a serius incident has ccurred, it wuld be apprpriate fr an rganisatin t undertake its wn investigatin until it is clear that the facts require an independent investigatin t be cmmissined. This wuld seem a sensible apprach althugh nce again this will be a matter that CQC will need t mnitr as part f its inspectin regime. in part 116: Where meetings are held between cmplainants and the Trust as part f the cmplaints prcess, there shuld be advcates and advice readily available t all cmplainants wh want thse frms f supprt. At the mment Lcal Authrities are respnsible fr cmmissining NHS cmplaints advcacy services but the funding is limited. It is nt clear hw an extended advcacy netwrk fr NHS cmplainants will be funded r cmmissined in the future but it is clear frm the evidence frm the inquiry and the cnclusins frm Francis and the Clywd and Hart review that this is a service that is urgently required. The lcal Healthwatch England Netwrk will als have a rle in scrutinising cmplaints data acrss trusts in rder t spt particular themes and recurring issues. The review als recmmends that patients shuld be ffered independent advcacy in supprt as they g thrugh the cmplaints prcess. Lcal authrities currently cmmissin advcacy services but the gvernment sees a rle fr Healthwatch England wrking with the Department f Health and thers t help set the standards f gd advcacy. 5

6 Recmmendatin Supprt fr Cmplaints 117: A facility shuld be available t independent cmplaints advcacy services, advcates and their clients fr access t expert advice in cmplicated cases. in part Learning and Infrmatin frm Cmplaints 118: A summary f each upheld cmplaint relating t patient care with the trust respnse shuld be published n its website. in part Analysis The gvernment have stated that the Department f Health will wrk with Healthwatch England and the Lcal Gvernment Assciatin t develp a set f gd practice standards fr NHS Cmplaints Advcacy Services. These standards may be expected t include access t clinical advice in what is described as apprpriate cases. As this service is currently cmmissined by Lcal Authrities the ability t btain expert evidence within the cmplaints prcess may be different in different areas. Sme clinical negligence slicitrs already persuade their clients t pursue cases thrugh the NHS cmplaints service befre pursuing litigatin and if there is a chance f btaining expert evidence thrugh a cmplaint it is likely this ptin will becme even mre attractive. It is anticipated that the Department f Health will begin an evaluatin f the current arrangements fr cmmissining NHS cmplaint advcacy services at sme pint in The Department f Health will ensure that every hspital will publish infrmatin quarterly n the cmplaints it receives. This will include the numbers f cmplaints received and the number f cmplaints that have been subsequently referred t the Health Service Ombudsman. There will nw be a requirement fr trusts t publish what lessns have been learned and what imprvements have been made as a result f the cmplaint. This infrmatin is currently required by cmmissiners but will nw be made mre publicly available. It seems the gvernment is nt ging s far as t require a summary f each upheld cmplaint t be made available n the trust s website as recmmended by Francis. The gvernment als accepts the Clwyd/Hart recmmendatin that there shuld be bard led scrutiny f cmplaints which will include a review f the actin taken and the evaluatin f the effectiveness f the plan. If bard invlvement is t be at all effective they will als need t audit the actin plans created t ensure that the changes have been carried ut as indicated. 119: Overview and Scrutiny Cmmittees and Lcal Healthwatch shuld have access t detailed infrmatin abut cmplaints. 120: Cmmissiners shuld require access t all cmplaints infrmatin as and when cmplaints are made and shuld receive cmplaints and their utcmes n as near r real-time basis as pssible. in part The gvernment cnfirms that trusts shuld seek t prvide these rganisatins with the cmplaints data that they request as lng as cnfidentiality is maintained. There will als be the published data abut cmplaints as discussed abve. The gvernment cnsiders that requiring a trust t prvide all cmplaints infrmatin t their cmmissiners will pse a significant bureaucratic burden n bth the service prvider and the cmmissining bdy. There is already a requirement t publish cmplaints infrmatin t the cmmissiners, beynd this the gvernment has stated that the Department f Health will wrk with NHS England and ther key partners t determine the mst effective mechanism thrugh which t achieve the utcmes frm the recmmendatins. This may be a lng way rund saying, this recmmendatin is nt accepted!! 6

7 Recmmendatin 121: CQC shuld have access t infrmatin abut the mst serius cmplaints. The CQC lcal inspectrs shuld be charged with infrming themselves f such cmplaints and the detail underlying them. Handling Large Scale Cmplaints 122: Where there are large scale failures f clinical service (as at Mid-Staffs) there shuld be prmpt arrangements made including cunselling etc and the respnsibility fr such arrangements shuld reside with the Natinal Quality Bard. Analysis The gvernment states that the Care Quality Cmmissin will review hw it makes best use f the cmplaints that it receives directly frm individuals as well as aggregated trends. This recmmendatin puts a specific respnsibility upn lcal inspectrs at CQC t the extent that they will be charged with lking at individual cmplaints and the detail underlying them. Hw this will wrk in practice is unclear. Culd it be like previus prcess where the regulatr became invlved befre the matter was referred t the Ombudsman? Will the inspectrs be lking at the quality f the respnse r whether there was an trends indicated within the cmplaint? Whether CQC inspectrs have the resurces t d justice t this recmmendatin is smething we will be able t assess in the future. The gvernment cnsiders that such actins shuld be a respnse agreed jintly between the trust invlved and the Care Quality Cmmissin, Mnitr and the NHS Trust Develpment Authrity as apprpriate althugh the situatin (it is hped) wuld be rare. in principle Rle f Cmmissiners and Prvisin f Supprt fr Cmplaints 133: Cmmissiners shuld be entitled t intervene in the management f an individual cmplaint n behalf f a patient where it appears t them that it is nt being dealt with satisfactrily. in principle Cmplaints t MPs 151: MPs are advised t cnsider adpting sme simple system fr identifying trends in the cmplaints and infrmatin they receive frm cnstituents. They shuld als cnsider whether individual cmplaints imply cncerns f wider significance than the impact n ne individual patient. in principle The gvernment is cncerned that it risks creating uncertainty ver rles and respnsibilities in the management f cmplaints. Clarity and cnsistency are critical fr the patient. The gvernment ntes that the standard NHS cntract already prvides cmmissiners with pwers t intervene in certain circumstances in cmplaints, fr example t require remedial actin t impse financial sanctins, t suspend services r terminate the cntract. Hwever, the gvernment cnsiders that enabling cmmissining bdies t intervene in the management f an individual cmplaint culd undermine the fundamental principle that lcal rganisatins themselves are in the first instance respnsible fr seeking reslutin f the cmplaint. The hesitancy frm the gvernment t accept this recmmendatin wuld seem sensible as this almst creates anther layer in the cmplaints prcess as well as the CQC invlvement as nted abve. The gvernment des nt cnsider it is fr them t advise MPs n the systems that they emply t identify the wider significance f cmplaints but the Department f Health recgnises insights which can be gained frm letters written t MPs. The gvernment is reluctant t impse systems n MPs in rder t establish hw they identify the wider significance f individual cmplaints but the Department f Health is willing t wrk with regulatrs and any interested MPs whilst respecting their psitin as an elected ffice hlders in rder t share best practice and advice (all wrded very carefully!). Of curse this recmmendatin cmes frm the fact that patients had cmplained t their MPs abut care they had received at Mid Staffs but this did nt achieve any real insight int the issues. 7

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